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THE  MEDICAL  COMPLICATIONS, 
ACCIDENTS  AND  SEQUELS 

OF 

TYPHOID  OR  ENTERIC  FEYER. 


BY 

HOBART  AMORY  HARE,  M.D.,  B.Sc., 

PROFESSOR  OF  THERAPEUTICS  IN  THE  JEFFERSON  MEDICAL  COLLEGE  OF  PHILADELPHIA  ;  PHYSICIAN 

TO  THE  JEFFERSON  MEDICAL  COLLEGE  HOSPITAL  ;   LAUREATE  OF  THE  MEDICAL  SOCIETY  OF 

LONDON,  OF  THE  ACADEMIE  ROYALE  DE  MEDICINE  DE  BELGIQUE,  ETC. 


WITH  A  SPECIAL  CHAPTER  ON  THE 

MENTAL  DISTURBANCES  FOLLOWING  TYPHOID  FEVER 


BY 


F.  X.  DERCUM,  M.D., 


CLINICAL  PROFESSOR  OF  DISEASES  OF  THE  NERVOUS  SYSTEM  IN   THE  JEFFERSON  MEDICAL  COLLEGE. 


LEA  BROTHERS  &  CO., 
PHILADELPHIA   AND    NEW    YORK. 

18  9  9. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1S99,  by 

LEA   BROTHERS   &   CO. 
In  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


DORSAK,     PRINTER. 
PHILADELPHIA. 


THIS 


ESSAY   .IS 


DEDICATED 
TO    MY     HONORED     COLLEAGUE, 

W.  W.  KEEX,  M.D.,  LL.D., 

PROFESSOR   OF   THE   PRINCIPLES   OF   SURGERY   AND   OF   CLINICAL   SURGERY 

IN    THE 

JEFFERSON  MEDICAL  COLLEGE 

OF  PHILADELPHIA. 


PREFACE. 


At  the  present  time  there  are  few  diseases  so  widespread  as 
typhoid  fever,  and  the  literature  concerning  it  is  very  great. 
Systems  of  medicine  and  text-books  innumerable  deal  with  its 
ordinary  manifestations,  and  touch,  necessarily  but  briefly,  upon 
its  accidents,  its  complications,  and  its  sequela?.  Anyone  who  has 
had  even  a  limited  experience  with  typhoid  fever  has  met  with 
cases  in  which  the  manifestations  wandered  so  far  from  the  clas- 
sical descriptions  of  the  disease  as  to  be  puzzling  and  obscure,  or 
with  instances  in  which  the  malady  has  been  so  altered  in  its 
course  by  intercurrent  affections  as  to  be  unusual  and  to  call  forth 
all  the  diagnostic  knowledge  and  therapeutic  skill  of  the  phy- 
sician. The  following  pages  deal  with  these  aberrant  forms  of 
the  disease  and  the  courses  which  they  pursue. 

As  mental  disorders  sometimes  complicate  typhoid  fever,  I 
have  asked  my  colleague,  Dr.  Dereum,  to  add  a  chapter  on  this 
phase  of  the  subject,  which  is  of  great  interest. 

Finally,  I  desire  to  acknowledge  my  great  indebtedness  i" 
the  several  authors  who  have  enriched  medical  literature  by 
special  contributions  to  this  subject,  and  from  whose  writings 
and  bibliographical  researches  I  have  gained  much  valuable 
material.  The  first  of  these  is  the  essay  of  my  honored  col- 
league, Dr.  W.  W.  Keen,  on  the  Surgical  <  bmplicaMons  and 
Sequelae,  of  Typhoid  Fever.  In  many  instances  I>r.  Keen,  in  com- 
pleting his  statistics,  steps  into  the  bound-  of  medicine,  in  distinc- 


vi  PREFACE. 

tion  from  surgery,  and  in  this  way  our  studies  sometimes  overlap. 
Another  writer  to  whom  all  subsequent  authors  on  typhoid  fever 
are  indebted  is  Liebermeister,  whose  classic  article  in  Ziemssen's 
Encyclopaedia  is  well  known.  I  am  also  anxious  to  acknowledge 
my  indebtedness  to  the  writings  of  Osier,  Mason,  and  Fitz. 

222  South  Fifteenth  St.,  Philadelphia, 
Apeil,  1899. 


CONTEXTS. 


<  NAPTER  I. 
General  Considerations 17 

CHAPTER  II. 

Varieties  of  Onset 37 

CHAPTER  HI. 

The  Aberrant  Symptoms,  States,  ob  Complications  of  the  Well- 

developed  Stage  of  the  Disease 63 

CHAPTER  IV. 
The  Complications  of  the  Period  of  Convalescence      .        .         .174 

CHAPTER  V. 
The  Conditions  which  Ape  Typhoid  Fever 253 

CHAPTER  VI. 
Duration  and  Immunity  to  Second  Attacks 262 

CHAPTER  VII. 
The  Mental  Complications 265 


THE  MEDICAL  COMPLICATIONS  AND  SEQUELE  OF 
TYPHOID  OR  ENTERIC  FEVER. 


CHAPTER  I. 

GENERAL  CONSIDERATIONS. 

It  may  be  said  by  those  who  are  disposed  to  be  critical,  that 
an  essay  dealing  with  the  medical  complications  and  seqnelse  of 
typhoid  fever  must  of  necessity  deal  with  the  disease  in  so  wide 
and  general  a  manner  as  to  include  practically  all  that  we  know 
concerning  it ;  but,  while  this  is  to  a  certain  extent  true,  on  the 
other  hand,  it  is  manifest  that  the  important  subjects  of  etiology 
and  pathology  will  not  find  space  for  their  consideration,  and  that 
the  simple  unaltered  forms  of  the  malady  will  only  have  to  be 
described  sufficiently  to  indicate  the  real  variations.  No  one  who 
has  had  any  experience  with  this  disease  can  fail  to  have  noted 
that  it  presents  widely  different  symptoms  in  degree  and  in  kind, 
not  only  in  different  epidemics,  but  in  different  individuals,  and 
in  the  same  individual  at  different  periods  of  a  single  attack.  In 
some  patients  the  illness  is  so  mild  as  to  be  only  a  moderate  indis- 
position ;  in  others  so  malignant  that  death  speedily  ensues,  and 
yet  in  nearly  all  cases  there  are  certain  manifestations  which  when 
grouped  together  render  it  possible  to  make  a  diagnosis  fairly  cer- 
tain. A  febrile  course,  characterized  by  malaise,  headache,  fever, 
drowsiness,  intestinal  disorder,  enlargement  of  the  spleen  and  liver, 
the  eruption  of  rose  spots,  and  the  confirmatory  Widal  test,  may  be 
considered  to  represent  true  uncomplicated  typhoid  fever  ;  and  with 
cases  presenting  these  general  symptoms  this  essay  will  not  deal. 
On  the  other  hand,  the  object  in  view  is  to  di-eiiss  three  classes  of 

2 


18       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

the  manifestations  of  typhoid  infection,  namely,  (a)  those  ordinary 
symptoms  of  onset  and  complete  development  which,  by  reason  of 
moderation  or  modification  or  exaggeration,  become  interesting  or 
dangerous  in  themselves  ;  (6)  those  which  are  so  rarely  met  with 
during  onset  or  the  course  of  the  malady  in  ordinary  cases  that 
they  can  be  considered  as  distinctly  complicating  conditions,  and 
(c)  those  results  of  the  disease  which,  coming  on  after  it  is  about 
to  cease  in  itself,  still  retard  or  interfere  with  the  rapid  and  normal 
return  of  the  patient  to  perfect  health. 

I  am  well  aware  that  at  certain  points  it  will  seem  that  the 
dividing  line  between  the  ordinary  symptoms  and  those  considered 
in  these  pages  is  overstepped,  and  while  it  is  not  my  intention  to 
avoid  this  overstepping  when  the  complete  discussion  of  the  con- 
dition is  necessary  to  a  thorough  study  of  the  process  under  con- 
sideration, these  ordinary  symptoms  will  not,  as  a  rule,  be  gen- 
erally considered. 

Before  proceeding  to  a  clinical  study  of  the  disease,  it  is  inter- 
esting to  note  that  its  frequency,  severity,  and  mortality  are  dis- 
tinctly on  the  wane.  While  isolated  epidemics  may  range  in 
severity  from  mild  to  severe,  and  produce  a  mortality  from  less 
than  1  per  cent,  to  almost  50  per  cent.,  the  average  being  at  one 
time  about  25  per  cent.,  the  mortality  is  now  much  less  than  this, 
and  often  only  10  per  cent.,  and  in  private  houses  where  the  family 
is  well  enough  placed  to  give  the  patient  every  aid,  it  is  often 
less  than  5  per  cent.,  even  when  the  treatment  instituted  is  not  all 
that  could  be  desired. 

These  changes  have  been  produced  by  improved  sanitation,  a 
natural  modification  in  the  severity  of  the  infection,  coupled,  per- 
haps, with  an  increased  resistance  on  the  part  of  the  individual, 
and  by  better  treatment,  and  as  they  bear  an  interesting  relation  to 
other  modifications  of  the  malady,  may  be  discussed  at  this  point 
with  propriety.  In  regard  to  the  effect  of  improved  sanitation  it 
can  be  pointed  out  that  Mosny  has  shown  that  the  death-rate  of 
Vienna  decreased  from  12.05  per  10,000  to  1.1  after  a  pure  water- 
supply.  In  Dantzic  the  mortality  has  fallen  from  10  per  10,000 
to  2.4,  and  finally  to  1.5  per  10,000.     In   Stockholm  it  fell  from 


GENERAL  CONSIDERATIONS.  19 

5.1  in   1877  to   1.7  in   1887.     So,  too,  in  Boston  from  17.4  in 
1846-49  to  5.6  in  1870-84. 

The  following  table  is  of  interest  in  this  connection  : 

Mortality  in  Munich  from  1851  to  1896. 


Year. 

Inhabitants. 

Annual. 

Per  100,000 
inhabit' nts. 

Year. 

Inhabitants. 

Annual. 

Per  100.000 
inhabit'nts. 

1851, 

123,957 

123 

99.0 

1874, 

181,300 

289 

159.0 

1852, 

125,588 

152 

121.0 

1875, 

187,200 

227 

121.0 

1853, 

127,219 

235 

184.0 

1876, 

193,024 

130 

67.0 

1854, 

128,850 

293 

227.0 

1877, 

205,000 

173 

84.0 

1855, 

130,481 

253 

193.0 

1878, 

211,300 

116 

55.0 

1856, 

132,112 

384 

291.0 

1879, 

217,400 

236 

109.0 

1857, 

133,847 

390 

291.0 

1880, 

223,700 

160 

72.0 

1858, 

135,733 

453 

334.0 

1881, 

230,028 

41 

18.0 

1859, 

137,005 

240 

175.0 

1882, 

236,400 

42 

18.0 

1860, 

140,624 

153 

109.0 

1883, 

242,800 

45 

19.0 

1861, 

144,334 

172 

119.0 

1884, 

249,200 

34 

14.0 

1862, 

148,200 

300 

202.0 

1885, 

255,600 

45 

18.0 

1863, 

154,602 

252 

163.0 

1886, 

262,000 

55 

21.0 

1864, 

160,828 

397 

247.0 

1887, 

268,400 

28 

10.0 

1865, 

167,054 

338 

202.0 

1888, l 

292,800 

31 

10.5 

1866, 

168,265 

342 

203.0 

1889, 

306,000 

31 

10.1 

1867, 

169,476 

88 

52.0 

1890, 

331,000 

28 

8.5 

1868, 

170,688 

136 

80.0 

1891, 

357,000 

24 

6.4 

1869, 

170,000 

190 

111.0 

1892, 

372,000 

11 

3.0 

1870, 

170,000 

254 

149.0 

1893, 

385,000 

57 

14.8 

1871, 

170,000 

220 

129.0 

1894, 

393,000 

10 

2.5 

1872, 

169,693 

407 

240.0 

1895, 

400,000 

15 

3.7 

1873, 

175,500 

230 

131.1 

1896, 

412,000 

14 

3.4 

The  effect  of  improved  sanitation  is  to  decrease  the  virulency 
of  infection,  and  for  this  reason  there  follows  a  decreased  severity 
of  illness  and  a  decreased  percentage  of  mortality.  X<>t  only  are 
these  facts  true  of  the  cities  just  named,  but  it  is  also  true  that 
the  frequency,  severity,  and  mortality  of  typhoid  fever  arc  steadily 
decreasing  all  over  the  world,  as  is  shown  by  the  following  inter- 
esting tables  of  Dreschfeld  in  regard  to  England  in  general  and 
London  and  Manchester  in  particular  : 

1  This  table  is  taken  from  Pettenkofer's  "Munich  a  Healthy  City,"  up  to  1887 
inclusive  ;  after  1887  from  returns  obtained  from  the  Statistical  Bureau. 


20       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 


Annual  Mortality, 


Period. 


per  Million  Persons  Living,  from  Fever  in 
England. 
Enteric 


Period. 


Enteric 


eases. 

cases. 

1838 

.  1228 

1866    .    .    .986 

1839 

.  1010 

1867 

.   778 

1840 

.  1089 

1868 

.   895 

1841 

932 

1869 

390 

1842 

1004 

1870 

388 

1843 

1871 

.   371 

1844 

1872 

377 

1845 

1873 

376 

1846 

1874 

.   374 

1847 

1807 

1875 

.   371 

1848 

1266 

1876 

.   309 

1849 

1044 

1877 

.   279 

1850 

865 

1878 

306 

1851 

997 

1879 

231 

1852 

1022 

1880 

261 

1853 

1008 

1881 

212 

1854 

1015 

1882 

229 

1855 

875 

1883 

228 

1856 

847 

1884 

236 

1857 

988 

1885 

175 

1858 

918 

1886 

184 

1859 

806 

1887 

185 

1860 

652 

1888 

172 

1861 

767 

1889 

176 

1862 

919 

1890 

179 

1863 

874 

1891 

168 

1864 

960 

1892 

137 

1865 

1089 

EATH-RATE  EROJI  J 

Enteric  Fever 

in  London  and  Manchester 

per  Million. 

Year.        Londo 

n.  Manchester. 

Year.        London.  Manchester 

1871   .    .  267 

450 

1883   .    .  247     200 

1872   . 

.  242 

400 

1884 

.  234     190 

1873   . 

.  269 

460 

1885 

.  150     170 

1874   . 

.  256 

390 

1886 

.  154     290 

1875   . 

.  235 

440 

1887 

.  151     310 

1876   . 

.  217 

420 

18S8 

.  169     330 

1877   . 

.  251 

290 

1889 

.  130     310 

1878   . 

.  283 

310 

1890 

.  146     270 

1879   . 

.  229 

180 

1891 

.  132     370 

1880   . 

.  186 

260 

1892 

.  102     240 

1881   . 

.  254 

170 

1893 

.  161     250 

1882   . 

252 

250 

GENERAL  CONSIDERATIONS.  21 

These  figures  are  exhibited  graphically  in  the  following  chart : 

Fig.  1. 


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Chart  showing  decreasing  mortality  of  typhoid  fever  per  million  persona  livim 
in  England,  London  and  Manchester. 

Solid  line,  England.     Broken  line,  London.     Dotted  line,  Manchester. 


Xot  only  is  the  decrease  in  mortality  seen  in  England,  bul  in 
Philadelphia  and  New  York,  as  follows.  The  decrease  in  eases 
and  in  mortality  in  Philadelphia  is  shown  in  the  following  chart 
in  broken  and  complete  lines  (  Fig.  '2)  : 


22       COMPLICATIONS  AND  SEQUEL JE  OF  TYPHOID  FEVER. 

Fig.  2. 


NUMBER 

OF 

CASES 

> 

<  S 

c  o 
2     ' 

CO 
30 

CO 

CO 
CO 

o 

33 

1-1 
33 
30 

CO 

C3 

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BETWEEN 

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19 

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18 

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3600-3300 

17 

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3300-3000 

16 

V 

V 

3000-2700 

15 

\ 

2700-2400 

14 

\ 

2400-2100 

13 

\ 

2100-1800 

12 

1800-1500 

11 

V  ' 

Chart  showing  the  morbidity  and  mortality  of  typhoid  fever  in  Philadelphia. 
Notwithstanding  the  present  epidemic  which  in  1898  raised  the  morbidity  from 
between  2700  and  3000  to  over  4500,  it  will  be  seen  from  the  dotted  line  that  the 
mortality  per  cent,  still  decreased. 

Solid  line,  morbidity.    Dotted  line,  mortality. 


Year. 

1888 
1889 
1890 
1891 
1892 
1893 
1894 
1895 
1886 
1897 
1898 


Philadelphia. 

Cases. 

Deaths. 

.     3573 

785 

4631 

736 

3182 

566 

3531 

683 

2304 

440 

2519 

456 

2357 

370 

2748 

469 

2490 

402 

2994 

401 

4749 

566 

Per  cent,  of 
mortality. 

21.9 

15.8 

20.9 

19.3 

19.1 

18.1 

15.7 

17.0 

16.1 

13.3 
11.91 


These  statistics  go  back  as  far  as  the  comparative  records 
extend,  and  do  not  include  the  1348  soldiers  with  typhoid  fever 
who  returned  from  the  Spanish- American  war  in  1898,  but  only 
the  regular  population  of  the  city.  If  the  soldiers  are  added,  to 
the  number  of  1348,  we  find  that  6097  cases  of  enteric  fever 
occurred  in  Philadelphia  in  1898.  The  mortality  of  the  city 
population  was   11.91,  that  of    the   soldiers   5.41,  which   would 


GENERAL   CONSIDERATIONS. 


23 


make  the  total  percentage  10.47  in  6097  cases.  The  low  mor- 
tality of  the  soldiers  is  a  tribute  to  hospital  treatment,  for  in  many 
cases  these  men  were  transported  hundreds  of  miles  when  very  ill, 
and,  as  a  rule,  had  not  had  the  food  and  care  which  are  so  neces- 
sary to  the  safe  conduct  of  a  typhoid  case.  Again,  while  the 
frequency  of  the  disease  has  risen  from  2994  cases  in  1897  to 
4749  cases  in  1898,  the  mortality  is  only  11.91  for  1898,  or, 
if  the  soldiers  are  included,  making  6097  cases,  10.47  per  cent. 


Fig.  3. 


NUMBER 

OF 

CASES 

i-t- 

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12 

\ 

30 

11 

\     1 
\    1 

25 

10 

1/ 

20 

9 

i 

Chart  showing  morbidity  and  mortality  per  cent,  at  the  Philadelphia  Hospital 
for  ten  years  (1888-1897  inclusive).  Both  the  morbidity  and  mortality  are  de- 
creased. 

Solid  line,  morbidity.     Dotted  line,  mortality. 


As  only  a  little  over  two  months  of  1899  have  elapsed  the  statis- 
tics for  this  year  cannot  be  included  in  Fig.  2  ;  but  it  is  inter- 
esting to  note  that,  while  this  wide-spread  epidemic,  due  to  bad 
water,  has  persisted  and  increased,  the  mortality  j>cr  cent,  has  not 
increased.  Thus  in  1899,  up  to  March  13th,  no  less  than  3424 
cases  of  typhoid  fever  occurred  of  which  360  cases  died,  or  10.51 
per  cent. 


24       COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER 

Fig.  4. 


NUMBER 

OF 

CASES 

00 
CO 
CO 
H 

© 

CO 

CO 

H 

0 

© 

CO 
H 

H 

o 

en 

© 
CO 
H 

w 

© 
CO 

H 

0 
CO 
H 

0 

© 

CO 
H 

0 
0 
CO 
H 

© 

CO 
H 

1400 

13SO 

1300 

1350 

/ 

13  OO 

/ 

1150 

/ 

llOO 

1 

1050 

lOOO 

9oO 

900 

8oO 

soo 

Chart  showing  decreasing  number  of  cases  annually  in  New  York.1 


Fig.  5. 


ANNUAL 
DEATH  RATE 

OF 
NEW  YORK 

0 
CO 
00 
H 

N 

00 

CO 
H 

00 

00 
00 
H 

© 
00 
00 

H 

0 

© 

CO 

H 

H 

© 

X 
H 

01 

© 

H 

CO 

0 

I 

H 

© 
I 

H 

0 

© 

00 
n 

0 

0 
30 
H 

O 
CO 

H 

O.2o 

A 

0.2-I 

/ 

\ 

0.23 

N 

y 

/ 

\ 

•,J 

0.2S 

V 

V 

0.21 

0.20 

0.19 

O.IS 

0.17 

0.16 

0.15 

Chart  showing  decreasing  death-rate  from  typhoid  fever  in  New  York  City. 


1  A  comparative  chart  of  the  number  of  cases  and  of  mortality  per  cent,  from 
these  figures  is  not  given,  as  Dr.  Biggs,  of  the  New  York  Health  Office,  writes 
that  only  recently  have  the  cases  been  generally  reported,  and  even  now  many 
are  not  reported. 


GENERAL  CONSIDERATIONS. 


25 


New 

York. 

Year. 

Cases. 

Deaths. 

Year. 

Cases. 

Deaths 

1888   . 

.  1108 

364 

1893   . 

.  1008 

381 

1889   . 

.  1414 

397 

1894   . 

.   792 

326 

1890   . 

.  1100 

352 

1895   . 

.   965 

322 

1891   . 

.  1342 

384 

1896   . 

.  1002 

297 

1892   . 

.   1140 

400 

1897   . 

.  1004 

299 

The  chart  on  preceding  page  from  the  New  York  Health  Report 
shows  a  decrease  in  death-rate  from  typhoid  fever  (Fig.  5)  : 

When  we  consider  that  the  population  of  these  cities  has  in- 
creased enormously,  the  great  decrease  in  the  frequency  of  the 
disease  and  in  its  mortality  is  very  notable. 

These  tables  are  supported  by  the  statement  of  Billings,  that 
in  Norway  from  1888  to  1891  the  mortality  from  typhoid  fever 
was  755  in  7467  cases,  or  less  than  10  per  cent.  In  the  recent 
Maidstone  epidemic  the  death-rate  in  1885  cases  was  only  7.5  per 
cent.,  and  a  similar  mortality  obtained  at  Plymouth,  Pa.  The 
death  rate  in  the  Worthing  epidemic  of  about  1000  cases  was  13 
per  cent. 

Bryant1  states  that  out  of  608  cases  treated  in  Guy's  Hospital 
from  1879  to  1893  14  per  cent.  died. 

Again,  hi  the  Gazette  Medicate  des  Hopitaux  of  July  10,1890,  we 
learn  that  a  collective  investigation  showed  that,  whereas  in  the 
period  from  1866  to  1881  the  mortality  from  typhoid  was  21.5 
percent.  ;  from  1882  to  1888  it  was  14.1  per  cent.,  and  in  1889, 
13.5  per  cent. 

We  may  assume  then  that  the  ordinary  mortality  of  typhoid 
fever  is  at  present  less  than  15  per  cent,  in  the  general  run  of 
cases,  and  that  in  good  hospitals  and  private  practice  with  good 
nursing,  that  it  varies  from  1  to  10  per  cent.,  the  more  so  as 
many  years  ago,  before  the  disease  had  become  modified,  Mur- 
chison  placed  it  at  17.45  among  27,951  cases  in  England. 

The  following  statistics  of  patients  treated  by  general  methods 
show  this  to  be  true,  and  with  or  without  baths  a  similar  doorcase 
in  mortality  is  evident  : 


1  Guy's  Hospital  Reports,  1893. 


26       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 


Basel  ( Liebermeister ) 
Basel  (Liebermeister) 
Maidstone,  England    .... 

Boston  (Mason)  ...... 

Homerton  (Collie)       .         .         .         . 

Glasgow  (Collie)         .         .         .         . 

Societe  Medicale  des  Hopitaux  (1879)1 
Jaccoud       ...... 

Riess  ....... 

Boston  (Shattuck)       . 

Germany  (?)  Brand  has  collected 


Cases. 

Per  cent,  of 
mortality. 

Treatment. 

223 

11.7 

Calomel. 

239 

14.6 

Iodide. 

1885 

7.5 

General. 

676 

10.4 

General. 

677 

9.5 

General. 

618 

8.2 

General. 

1979 

12.47 

665 

10.8 

General. 

900 

7.5 

Tepid  baths. 

237 

9.8 

Expectantly  and 
cold  sponging. 

19,017 

7.8 

All  kinds  of  cold 



baths. 

27,116 


10.0: 


In  other  words,  27,116  cases  in  Switzerland,  America,  England, 
Germany,  and  France  show  that  good  nursing  and  careful  non- 
meddlesome  treatment  will  give  a  mortality  of  about  10  per  cent. 
The  wide  distribution  of  these  cases  and  the  large  number  of 
clinicians  give  us  a  standard  average. 

At  Basel  in  1873,  under  the  cold  bath,  there  were  163  cases, 
with  a  mortality  of  10.4  per  cent. ;  during  the  same  year  at  Glas- 
gow without  baths,  275  cases,  with  a  mortality  of  9.4  per  cent. ; 
and  305  at  Homerton,  with  a  mortality  of  9.5  per  cent.  In  1874 
at  Basel  the  water  cases  were  200,  with  a  mortality  of  10.5  per 
cent. ;  at  Homerton  372,  with  a  mortality  of  9.6  per  cent. ;  at 
Glasgow  343,  with  a  mortality  of  7  per  cent. 


Basel         (1873) 
Glasgow        " 
Homerton     " 
Basel         (1874) 
Glasgow        " 
Homerton     " 


No.  of  cases. 

Treatment. 

Mortality  per  ct 

.     163 

Bath 

10.4 

.     275 

General 

9.4 

.     305 

General 

9.5 

.     200 

Bath 

10.5 

.     343 

General 

7.0 

.     372 

General 

9.6 

1  These  statistics  are  based  upon  the  fact  that  twenty-one  chiefs  of  hospital 
service  reported  to  the  Societe  Medicale  des  Hopitaux  (1890)  916  cases  with  114 
deaths,  or  12.44  per  cent,  under  general  treatment;  and  for  1888  and  1889  this 
report  also  mentions  1063  cases  so  treated  with  133  deaths,  or   12.51  per  cent. 


GENERAL  CONSIDERATIONS.  27 

Of  the  fact  that  a  change  in  type  has  taken  place  in  enteric 
fever,  I  do  not  think  there  can  be  any  doubt,  and  no  one  who 
has  watched  the  disease  during  the  last  fifteen  or  twenty  years,  or 
even  for  a  shorter  period  than  this,  can  fail  to  note  the  difference 
in  its  character.  Particular  attention  has  been  called  to  this  fact 
by  Sidney  Phillips1  and  James  F.  Goodhart.2  The  latter  writer 
says  :  "  I  agree  in  toto  with  what  Dr.  Sidney  Phillips  said  to  us 
that  '  typhoid  fever  tends  to  vary  with  the  conditions  associated 
with  its  origin,  and  though  such  variations  are  slight  individually 
and  gradual  in  evidence  in  their  sum,  they  suffice  in  time  to  pro- 
duce a  considerable  modification  of  the  original  disease.  There  is 
considerable  difference  in  the  symptoms  described  fifty  or  even 
twenty-five  years  ago  and  those  occurring  to-day.  The  difference 
is  marked  in  the  lessened  severity  of  the  abdominal  symptoms  ; 
the  tongue  is  now  often  moist  throughout  the  disease,  instead  of 
dry  and  baked ;  tympanites  and  diarrhoea  are  much  less  pro- 
nounced ;  probably  also  hemorrhage  and  perforation  are  less  com- 
mon ;  tremors  and  dilatation  of  the  pupils  are  now  uncommon  ;  and, 
instead  of  noisy,  active  delirium,  the  mind  is  often  clear  throughout 
even  fatal  cases.  The  typhoid  state  with  the  patient  sunk  deep  in 
bed,  unable  to  move  himself  and  unconscious  or  semi-conscious  for 
days,  is  now  quite  exceptional.  Dr.  Phillips  attributes  this  '  to  a 
lessened  tendency  to  ulceration  of  the  intestines,'  and  argues  that 
if  so  much  variation  of  type  has  taken  place  in  a  quarter  of  a 
century,  much  more  has  gone  on  in  fifty  years,  and  that  where 
conditions  existed  such  as  made  typhus  rife  the  distinctive  features 
of  typhoid  may  well  have  been  affected,  and  that  in  this  is  pos- 
sibly to  be  found  the  explanation  that  the  separate  diseases  were 
regarded  as  one." 

In  this  connection  the  question  of  the  frequency  of  typhoid 
fever  in  children  may  be  considered.  At  first  sight  it  would 
appear  that  in  this  class  of  patients  it  is  a  more  common  disease 
than  formerly,  but  this  is  only  because  it  was  not  recognized  and 
recorded. 

1  British  Medical  Journal,  November,  12,  1898.        2  Ibid.,  January  28,  1899. 


28       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

Typhoid  fever  in  children  is  by  no  means  as  rare  as  has  been 
supposed.  While  the  earlier  years  of  life  seem  to  be  blessed  with 
a  relative  immunity  to  the  disease,  there  is  no  doubt  that  it  often 
occurs  in  a  mild  form  and  is  not  correctly  diagnosed.  A  young 
child  sickens,  has  fever,  is  wretched,  has  moderate  diarrhoea  or 
constipation,  and  a  coated  tongue.  Debility  is  rapidly  developed, 
the  stomach  becomes  irritable,  and  the  fever  is  persistent,  even 
though  it  is  not  high.  After  an  illness  lasting  for  from  a  few  days 
to  several  weeks,  the  child  gradually  recovers,  and  the  diagnosis 
originally  made  is  adhered  to,  namely,  that  the  case  has  been  one 
of  "  simple  catarrhal  fever."  The  longer  one  practices  medicine 
the  more  strongly  the  idea  develops  that  such  a  thing  as  "  simple 
catarrhal  fever,"  does  not  exist  as  an  entity,  and  that  this  term 
covers  a  multitude  of  diagnostic  sins.  As  was  pointed  by  Lieber- 
meister  years  ago,  typhoid  fever  may  occur  even  in  adults  with 
these  mild  symptoms,  and  be  called  "  catarrhal  fever." 

It  may  be  laid  down,  however,  as  a  rule,  that  the  younger  the 
child  the  less  likely  is  it  to  have  enteric  fever,  and  that  the  prog- 
nosis is  usually  favorable  if  the  child  be  young.  In  other  words, 
the  older  the  child,  the  more  grave  the  prognosis.  On  the  other 
hand,  it  is  only  fair  to  state  that  Rocaz1  believes  that  while  the 
duration  of  the  fever  in  children  is  shorter  than  in  adults,  the 
fever  itself  is  apt  to  be  excessive ;  that  the  prognosis  is  grave 
under  three  years,  less  grave  at  four  years,  and  only  less  grave 
than  in  adults  when  the  child  is  above  five  years  of  age. 

This  question  of  how  frequently  typhoid  fever  does  occur  in 
children  is  of  great  importance.  At  the  head  of  those  who  advo- 
cate the  view  that  it  is  common  we  have  Ashley  and  Wright,2  who 
assert  that  "  children  and  young  people  are  more  susceptible  to 
typhoid  fever  than  are  adults,  though  it  is  not  common  in  children 
under  three  years  of  age."  This  is  certainly  an  excessive  state- 
ment, although  Pepper3  states  that  typhoid  fever  is  far  more  com- 
mon in  early  life  than  is  generally  recognized.     Henoch  records 

1  Annales  de  la  Polyclinique  de  Bordeaux,  1897. 

2  Diseases  of  Children.  3  American  System  of  Medicine,  vol.  ii. 


GENERAL  CONSIDERATIONS.  29 

376  cases  and  2<j  autopsies  in  children  from  this  disease,  and 
Barthez  and  Sanne  state  that  the  disease  is  as  frequent  among 
children  as  among  adults. 

On  the  other  hand,  there  is  an  immense  amount  of  evidence  to 
prove  that  the  disease  is  so  rare  as  to  be  almost  a  curiosity  in  chil- 
dren. Thus  William  Perry  Northrup  has  taken  the  statistics  of 
the  New  York  Foundling  Hospital,  the  New  York  Infant  Asy- 
lum, the  Children's  Hospital  of  Philadelphia,  and  finds  that  in 
the  twenty  years  at  the  New  York  Foundling  Hospital  with  1800 
cases  under  care,  1100  of  which  were  boarded  in  the  country, 
returning  to  the  hospital  when  ill,  not  a  single  case  has  been  seen 
by  himself,  J.  Lewis  Smith  and  O'Dwyer.  Further,  in  2000 
autopsies  on  children  Northrup  did  not  find  a  case,  perhaps  be- 
cause typhoid  fever  rarely  brings  a  child  to  autopsy,  and  during 
an  epidemic  in  Stamford,  Conn.,  in  1895,  out  of  400  cases  at  all 
ages,  but  four  cases  of  enteric  fever  developed  under  four  years  of 
age. 

Holt1  states  that  he  has  never  met  with  enteric  fever  in  a  child 
under  two  years  of  age.  He  never  saw  a  case  in  the  New  York 
Infant  Asylum  in  a  service  of  eight  years,  although  15,000  cases 
were  admitted  in  that  time.2  One  case  was  admitted  to  the  Babies' 
Hospital  in  seven  years  at  the  age  of  two  and  one-half  years. 

In  this  connection  it  is  interesting  to  note  that  Taupin,3  writing 
sixty  years  ago,  says  that  the  rarity  of  this  fever  in  children  is 
more  apparent  than  real,  and  points  out  that  the  mild  manifesta- 
tions of  the  disease  are  overlooked. 

Notwithstanding  these  statistics,  we  find  that  typhoid  fever 
does  occur  quite  frequently  in  the  hands  of  some  practitioners. 
Thus  Forchheimer1  treated  70  cases  in  1888  in  one  epidemic, 
and  Morse,  in  analyzing  284  cases  in  the  Boston  City  Hospital  in 
which  this  disease  appeared,  found  3  under  five  years  of  age,  77 
between  five  and  ten  years,  and  204  between  ton  and  fifteen  years. 

1  Diseases  of  Children. 

2  Probably  all  these  did  not  come  under  his  term  of  service. 

3  Journal  des  Connaissances  Me*d.  and  Chir.,  1839,  No.  7. 
1  American  Lancet,  March,  1889. 


30       COMPLICATIONS  AND  SEQUELjE  OF  TYPHOID  FEVER. 

Holt  quotes  970  cases  of  enteric  fever  in  children  collected  from 
eight  authors  whose  names  he  does  not  give.  Of  these  970  cases, 
8  per  cent,  occurred  under  five  years ;  42  per  cent,  between  five 
and  ten  years,  and  50  per  cent,  between  ten  and  fifteen  years. 
He  also  quotes  an  epidemic  of  115  persons,  of  whom  three  were 
under  two  years  of  age. 

Wightman1  has  recorded  24  cases  of  typhoid  fever  in  children 
under  thirteen  years  of  age ;  3  of  these  died,  and  typical  spots 
were  seen  in  15  ;  constipation  in  10,  and  typical  stools  in  only  3 
cases.  So,  too,  Davis2  has  recorded  33  cases  in  children,  all  of 
whom  were  under  ten  years  of  age,  and  in  all  of  whom  but  3  the 
disease  developed  abruptly. 

Ssokolow,3  in  a  study  of  581  cases  of  typhoid  fever,  the  majority 
of  which  occurred  between  four  and  ten  years,  found  that  it  was 
abortive  in  4.3  per  cent.,  mild  in  26  per  cent.,  ordinary  in  51  per 
cent.,  and  severe  in  18  per  cent.  In  3.6  per  cent,  there  was  an 
abrupt  onset  with  vomiting,  and  in  3.2  per  cent,  it  was  abrupt 
with  a  chill ;  diarrhoea  occurred  in  only  10  per  cent. 

Bridges  has  met  with  the  disease  in  infants  at  fifteen  and  eighteen 
months  of  age,  and  Bond  saw  eleven  children,  affected  in  one-house 
epidemic,  between  the  ages  of  three  and  twelve  years.  Read4  has 
collected  22  cases  between  four  and  one-half  months  and  ten 
years,  and  Griffith  reports  cases  at  three,  seven,  eleven,  and  thir- 
teen years.  England  records  one  at  eight  months  of  age,  and 
Boobbyer  one  in  an  infant  of  eight  months.  Murchison  recorded 
one  at  six  months.  Ogle  has  recorded  a  case  at  four  and  one-half 
months,  and  Fuller  one  at  five  months. 

Further  than  this,  Dr.  Mart,5  of  German,  Ohio,  has  recorded 
the  fact  that  in  six  years  he  had  treated  seventeen  cases  of  unques- 
tionable typhoid  in  children  ranging  from  fourteen  months  to  five 
years  of  age ;  that  three  of  these  cases  were  less  than  twenty-four 

1  British  Medical  Journal,  May  5,  1894. 

2  Alabama  Medical  and  Surgical  Age,  August,  1894. 

3  Centralblatt  fur  innere  Med.,  May  18,  1895. 

4  Brooklyn  Medical  Journal,  October,  1890. 

5  Cleveland  Medical  Gazette,  vol.  xii.  p.  510. 


GENERAL  CONSIDERATIONS.  31 

months  old,  and  in  each  Instance  there  were  other  members  of  the 
family  sick  with  the  fever  at  the  same  time,  showing  that  the 
infection  was  present  in  the  household. 

H.  J.  Lee,1  of  Cleveland,  reports  a  case  of  typhoid  fever  in  an 
infant  six  months  old,  and  states,  although  he  does  not  give  the 
reference  for  the  same,  that  he  finds  one  case  reported  as  young  as 
four  and  one-half  months  f  another  at  six  months,  and  a  good 
many  under  two  years. 

O'Malley3  records  three  cases  of  typhoid  fever  at  twenty-one 
months,  three  years,  and  six  years  in  one  family. 

Not  only  may  typhoid  fever  occur  in  very  young  children,  but 
it  is  to  be  remembered  that  this  source  of  infection  may  cause  the 
disease  among  adults.  Thus  Boobbyer4  records  an  instance  in 
which  out  of  a  family  of  eight  persons  five  became  infected 
through  an  infant  of  eight  months.  The  child  had  been  restless 
and  had  constant  diarrhoea,  but  the  fact  that  it  was  suffering  from 
typhoid  fever  was  not  recognized. 

That  severe  typhoid  fever  may  occur  very  early  in  life  is  shown 
by  the  statement  of  Osier,  that  perforation  of  the  bowel  from  this 
cause  has  occurred  in  a  child  five  days  old,  and  Earle  has  reported 
a  case  to  Keating  of  fatal  intestinal  hemorrhage  due  to  typhoid 
fever  at  twenty-two  months. 

Further  than  this,  Sbrana,5  who  has  treated  seventy-two  cases 
of  typhoid  fever  in  children  in  Tunis,  tells  us  that  a  symptom 
which  was  never  lacking  was  splenomegaly  appreciable  from  the 
fifth  or  sixth  day  of  the  fever.  The  nervous  symptoms  were  more 
marked  in  girls  than  in  boys.  The  mortality  was  11.1  per  cent., 
and  the  complications  were  meningitis,  suppuration,  parotiditis, 
peritonitis  from  perforation,  purulent  pleurisy,  aphasia  lasting  as 
long  as  three  weeks,  dilatation  of  the  stomach  during  convales- 
cence, and  orchitis. 

1  Cleveland  Journal  of  Medicine,  1897,  vol.  ii.  p.  400. 

2  Probably  Ogle's  case.  s  University  Medical  Magazine,  1896-97,  p.  637. 

4  British  Medical  Journal,  January  26,  IX'.io. 

5  Quoted   in  the  American  Journal  of  Obstetrics  for  March,  1899,  from   the 
Archives  de  M<?d.  des  Enfance,  January,  1899. 


32       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

"Wurtz1  records  the  case  of  a  girl  of  eight  years,  "who  developed 
a  swelling  over  the  sternum  during  the  second  "week  of  typhoid 
fever.  Puncture  drew  pus  and  an  incision  gave  exit  to  a  necrosed 
piece  of  the  sternum,  the  entire  body  of  the  bone  being  involved 
in  the  necrotic  process.  Typhoid  bacilli  were  demonstrated  micro- 
scopically in  the  pus.  Death  occurred  in  the  fifth  week.  At  the 
autopsy  an  abscess  lined  by  pyogenic  membrane  "was  found  between 
the  sternum  and  pleura,  extending  upward  to  the  manubrium. 
There  was  broncho-pneumonia  in  both  lungs,  and  in  the  ileum 
there  were  a  few  typhoid  ulcers,  the  rest  of  the  intestine  showing 
healing ;  the  right  arytenoid  cartilage  showed  a  chondritis. 

In  the  Maidstone2  epidemic  of  1897  and  1898,  22  per  cent,  of 
the  cases  admitted  to  the  hospital  were  in  children  under  ten 
years  of  age,  and  52  per  cent,  were  under  fifteen  years. 

I  think  it  is  fair  to  conclude  therefore  that  Taupin's  assertion, 
in  1839,  that  typhoid  fever  is  not  a  rare  disease  in  children  is 
correct. 

At  the  present  time  the  diagnosis  of  typhoid  fever  in  children 
must  rest  largely  upon  the  chance  development  of  the  character- 
istic rash  and  enlarged  spleen,  and  more  than  all  upon  the  Widal 
test,  for  the  moderation  in  all  the  symptoms  so  characteristic  of  the 
affection  in  childhood,  and  the  fact  that  a  swollen  spleen  and  liver 
and  a  coated  tongue  with  fever  are  so  commonly  met  with  in 
various  children's  ailments,  make  an  absolute  diagnosis  without 
this  test  in  many  instances  almost  impossible. 

Tvphoid  fever_/g__?ji2LcauiaftOM  in-~pregnancy,  but  wlien  it  occurs 
it  is  a  serious  matter,  for  abortion  often  follows,  particularly  if  the 
fever  be  high.  The  percentage  of  abortion  is  about  56  per  cent. 
In  310  cases  collected  by  Sacquin,  199  aborted.  The  mortality, 
according  to  Brieger,  was  19  in  91  cases,  and  according  to  Tinay, 
17  per  cent,  in  183  cases. 

Death  to  the  foetus  does  not  always  occur  as  a  result  of  preina- 

1  Quoted  in  the  American  Journal  of  Obstetrics  for  March,  1899,  from  the 
Jahrbuch  f.  Kinderheilkunde,  vol.  xliv.,  Xo.  1.  I  have  not  been  able  to  see 
the  original  article. 

2  Poole.    Guy's  Hospital  Keports,  1898.     Wrongly  labelled  on  cover  1896. 


GENERAL  CONSIDERATIONS.  33 

ture  birth  duo  to  typhoid  fever;  thus  Touvenaint1  reports  a  case 
of  premature  birth  at  the  end  of  the  seventh  month,  the  child 
surviving  and  the  mother  dying. 

Tvphoid  fever  may  also  affect  the  foetus  in  utero.  This  For- 
dyce  has  proved,  and  he  also  asserts,  that  the  child  may  survive. 
It  is  possible,  too,  for  it  to  escape  the  infection.  Flexner  has  exam- 
ined such  a  case  for  Osier. 

Griffith  found  the  "Widal  reaction  in  a  child  of  seven  weeks 
whose  mother  had  typhoid  fever  at  the  time  of  its  birth. 

So,  too,  fitienne2  has  recorded  the  examination  of  a  foetus  ex- 
pelled by  a  woman  in  the  fifth  month  of  pregnancy,  on  the 
twenty-ninth  day  of  typhoid.  The  spleen  and  intestines  of  the 
child  showed  no  signs  of  the  disease,  and  the  placenta  was  healthy, 
but  an  examination  of  the  blood  in  the  right  side  of  the  heart  and 
of  that  of  the  spleen  revealed  innumerable  typhoid  bacilli. 

Mosse  and  Daunic  also  record  a  case  in  which  a  woman  suffered 
from  typhoid  fever  in  the  eighth  month  of  pregnancy.  At  birth 
the  blood  of  the  child,  the  blood  of  the  placenta,  and  the  milk  of 
the  mother  gave  the  Widal  reaction,  as  did  the  child  thirty-three 
days  after  birth. 

Another  interesting  illustration  of  the  fact  that  the  foetus  may 
become  infected  by  the  typhoid  bacillus  through  the  mother  is 
shown  by  a  case  reported  by  Eberth,3  of  a  woman  who  suffered 
from  typhoid  fever  in  the  fifth  month  of  pregnancy  and  miscar- 
ried, and  in  the  cardiac  and  splenic  blood  of  the  foetus  the  specific 
bacillus  was  found. 

Mosse  and  Fraenkel4  have  made  a  report  upon  the  agglutination 
test  in  placental  blood  to  the  Societe  Medicalc  des  Hopitaux,  in 
which  they  confirm  the  statements  already  made,  that  the  Widal 
test  can  be  obtained  from  the  placenta,  and  also  that  it  is  possible 
to  obtain  it  from  the  milk  of  the  mother  and  the  blood  of  the 
foetus. 

1  Journal  de  Medicine  de  Paris,  July  8,  189-1. 

2  Gazette  Hebd.  de  Medecine  et  de  Cliirurgie.  1896,  No.  16. 

3  Centralblatt  fur  Bakteriologie  and  Parasitenkunde,  May  1:>,  lS'.io. 

4  Journal  des  Practiciens,  January  2<S,  ISSi). 

3 


34       COMPLICATIONS  AND  SEQUEL JE  OF  TYPHOID  FEVER. 

The  following  very  interesting  case  in  this  connection  has  jnst 
been  reported  to  nie  by  my  friend,  Dr.  Wilmer  Krusen  : 

Mrs.  B.,  aged  twenty-seven  years,  a  native  of  Ireland,  a  house- 
wife by  occupation,  was  admitted  to  the  hospital  February  7, 
1899,  eight  months  pregnant.  From  her  attending  physician  it 
was  learned  that  for  a  week  prior  to  her  admission  she  had  had  a 
typical  typhoid  temperature  and  stools,  but  no  spots.  On  admis- 
sion her  temperature  was  100.5°;  the  pulse  was  100  ;  respirations, 
24.  The  temperature  fell  steadily  till  it  reached  95°  at  10  A.M. 
of  February  8th,  remaining  there  all  that  day ;  the  pulse  ranging 
between  80  and  94,  and  the  respirations  between  18  and  32. 
About  1  a.m.,  February  8th,  she  developed  labor  pains,  which 
lasted  until  3  a.m.,  when  they  ceased  entirely ;  the  pains  were 
never  severe,  and  labor  progressed  very  slowly.  The  temperature 
was  subnormal  all  the  time,  but  began  to  rise  toward  morning,  and 
reached  99°  at  8  A.m.;  the  pulse,  100  ;  respirations,  36.  The  tem- 
perature continued  to  rise  slowly.  At  noon  on  February  9th  very 
mild  labor  pains  again  began,  but  soon  ceased.  At  3  p.m.  the 
child's  head  had  descended  entirely  without  any  pain  whatever.  ]So 
progress  being  made,  forceps  was  applied  and  the  child  delivered 
a  few  minutes  past  3  p.m.  Temperature,  100.4°;  pulse,  136  ;  respi- 
rations, 36.  Temperature  then  went  up,  and  at  6  p.m.  was  103.4°, 
and  continued  with  daily  remissions,  as  is  usual  in  typhoid.  A 
superficial  median  laceration  occurred ;  it  was  sewed  up,  but  no 
healing  process  took  place,  and  the  stitches  had  to  be  removed. 
About  the  tenth  day  after  admission,  the  temperature  became  very 
irregular,  ranging  from  97°  to  106.2°;  pulse  from  110  to  150; 
respirations,  20  to  44.  The  vaginal  discharge  had  been  copious 
and  offensive,  and  continued  so  until  the  twenty-second  day  in  the 
hospital.  The  temperature  continued  to  be  irregular  throughout 
the  remainder  of  the  disease.  From  February  18th  to  February 
24th  the  temperature  became  reversed,  so  that  it  was  highest 
about  6  a.m.  and  lowest  about  6  p.m.,  being  still  very  irregular. 
From  February  24th  the  temperature  again  assumed  its  former 
character,  highest  in  the  evening  and  lowest  in  the  morning.  The 
vaginal  discharge  had  completely  stopped  by  February  28th,  having 


GENERAL  CONSIDERATIONS.  35 

been  very  slight  for  the  preceding  three  or  four  days.  March  3d, 
the  temperature  was  98.4°  at  10  A.M.  ;  pulse,  92  ;  respirations,  24. 
The  child  progressed  nicely.  The  Widal  reaction  was  taken  March 
2d  with  a  very  high  dilution,  and  proved  to  be  negative,  though 
there  was  a  distinct  tendency  to  agglutination.  It  was  taken  again 
March  4th  with  a  dilution  of  1  part  of  serum  to  about  25  parts  of 
water.     The  result  was  a  positive  reaction  in  eleven  minutes. 

A  somewhat  similar  case  has  also  been  recorded  by  Batty  Shaw.1 
A  woman  suffering  from  typhoid  fever  in  the  fifth  month  of  preg- 
nancy and  her  child  gave  a  feeble  AVidal  test  five  weeks  after  birth 
on  two  occasions,  but  on  two  other  occasions  the  test  was  negative. 

Two  cases  illustrating  typhoid  infection  during  the  last  weeks 
of  pregnancy  have  recently  come  under  my  care,  having  been 
transferred  to  me  from  the  Jefferson  Maternity  Wards  by  Dr.  E. 
P.  Davis.  In  both  of  them  the  fever  began  practically  simul- 
taneously with  parturition,  indicating  that  the  patient  had  become 
infected  during  the  last  two  weeks  of  pregnancy.  In  neither  one 
of  them  were  the  typhoid  manifestations  severe  so  far  as  nervous 
and  circulatory  symptoms  were  concerned,  but  in  one  the  tempera- 
ture was  fairly  high  and  persistent.  The  blood  of  the  children 
did  not  give  the  Widal  test. 

In  patients  over  forty  years,  typhoid  fever  is  a  rare  but  grave 
disease,  the  mortality  increasing  with  the  years.  The  fever,  as 
already  indicated,  is  apt  to  be  mild,  but  death  comes  more  com- 
monly than  in  comparative  youth  from  complications  like  pneu- 
monia and  heart  lesions  (Fig.  6). 

Dreschfeld  has  reported  a  case  of  typical  typhoid  fever  in  a 
man  of  seventy-five  years,  and  another  in  a  man  of  eighty-two 
years.     In  the  latter  case  he  states  that  recovery  took  place. 

While  it  is  generally  true  that  the  period  of  incubation  of 
typhoid  fever  extends  over  a  period  from  ten  days  to  two  weeks, 
recent  reports  indicate  that  in  certain  instances  this  period  may 
only  cover  a  few  days.  Thus  Janehen-Graz2  has  recently  reported 
thirty-six  cases  of  typhoid  fever  occurring  among  soldiers,  in  whom 

1  London  Lancet,  1897,  vol.  ii.  p.  539. 

'-'  Miinchener  Medicinische  Wochenschrift,  1898,  p.  936. 


36       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 


definite  proof  was  adduced  that  they  had  all  become  infected  at 
the  same  time  by  drinking  infected  water.     As  a  result  the  incu- 


Fig 

.  6. 

AGE 

10 

11-16 

10-20 

21-25 

20-30 

31-35 

30-40 

11-45 

4G-50 

51—55 

50-00 

01 

PERCENT 
50 

4-0 

30 

20 

10 
0 

f 

/ 

_, 

f 

/ 

/ 

/ 

Chart  showing  the  increasing  mortality  of  typhoid  with  advancing  years. 

(CUKSCHMAN.  ) 

bation  period  in  three  cases  was  only  two  days,  in  seven  cases 
three  days,  in  six  cases  four  days,  and  in  thirteen  cases  five  to 
seven  davs. 


CHAPTER  II. 

VARIETIES  OF   ONSET. 

Befoee  attempting  to  consider  the  variations  which  take  place 
in  the  stage  of  onset  in  typhoid  fever,  it  is  necessary  to  have  some 
standard  type  of  an  average  case  of  the  disease  in  this  period. 
The  usual  mode  of  onset,  as  described  by  Dreschfeld  in  Allbutt's 
System  of  Medicine,  is  as  follows  : 

"  In  many  ordinary  cases  the  onset  is  insidious.  The  patient 
complains  of  pain  in  the  limbs,  of  excessive  fatigue,  of  cold  and 
chilly  sensations,  of  headache  often  very  severe,  of  loss  of  appe- 
tite, and  of  sleeplessness.  Epistaxis  is  a  very  common  symptom, 
and  generally  occurs  about  the  second  or  third  day  of  the  disease. 
These  symptoms  become  more  severe,  the  patient  has  to  take  to 
his  bed,  and  from  this  day  we  generally  reckon  the  duration  of 
the  fever.  In  many  cases,  however,  as  shown  by  the  changes  after 
death,  the  beginning  of  the  morbid  process  must  be  dated  from 
the  very  first  symptom.  The  tongue  becomes  furred,  and  is  at 
first  moist ;  there  is  a  steady  rise  of  temperature,  the  evening  tem- 
perature being  generally  one  and  a  half  degrees  (F.)  higher  than 
the  morning  temperature,  so  that  about  the  fourth  day  the  tem- 
perature reaches  103°  F.  or  104°  F.;  the  pulse  rises  to  90  or  100, 
rarely  higher  except  in  very  severe  cases,  or  in  very  young  or  de- 
bilitated subjects,  is  dicrotic  and  indicative  of  low  blood-pressure ; 
there  is  increased  thirst ;  the  abdomen  is  sliffhtlv  distended  and 
tender  on  pressure  ;  diarrhoea  may  as  yet  be  absent,  and  there  may 
be  constipation,  or  there  may  be  two  or  three  fluid  stools  from  the 
first.  Beyond  headache,  which  persists  for  a  few  days,  and  sleep- 
lessness, there  are  as  yet  no  other  symptoms  ;  the  skin  is  dry,  but 
there  are  paroxysms  of  profuse  perspiration.  The  spleen  is  as 
yet  but   little  enlarged,  and   there  are  as  yet  no  roseolar  spots, 


38       COMPLICATIONS  AND  SEQUELM  OF  TYPHOID  FEVER. 

though  when  perspiration  is  profuse  sudamina  are  noticed  ;  the 
urine  has  febrile  characters,  and  as  yet  does  not  show  the  diazo  re- 
action. This  stage  lasts  about  seven  days,  and  constitutes  the 
first  week  of  the  enteric  fever." 

If  this  be  taken  as  a  type  of  an  average  case,  we  find  at  once  that 
on  either  side  of  this  type  undoubted  cases  occur  which  by  their 
extreme  mildness  may  be  overlooked,  or  by  their  great  severity  may 
mislead  the  physician  into  the  diagnosis  of  some  more  acute  and 
rapidly  progressing  affection.  In  the  mildest  of  these  cases  there 
is  little  to  be  found  indicative  of  enteric  fever  save,  as  Lieber- 
meister  puts  it,  "  the  long  duration  of  an  apparently  trifling  indis- 
position in  which  the  patient  presents  a  general  impairment  of 
health,  malaise,  physical  and  mental  depression,  and  headache, 
with  loss  of  appetite,  the  tongue  being  coated,  and  the  pulse  often 
distinctly  slower  than  normal."  No  fever  may  be  present.  So 
moderate  may  all  the  symptoms  be  that  a  differential  diagnosis 
between  subacute  gastro  -intestinal  catarrh  and  mild  typhoid  fever 
may  be  practically  impossible  except  by  the  aid  of  Widal's  test, 
which  rarely  gives  results  so  early  as  the  days  of  onset.  Certain 
of  the  German  writers  have  gone  so  far  as  to  assert  that  all  cases 
of  subacute  catarrh  of  this  character  depend  for  their  existence 
upon  mild  typhoid  infection. 

Not  only  may  the  course  of  the  malady  be  very  mild  indeed, 
but  its  length  may  be  so  brief  as  to  throw  doubt  on  its  specific 
character,  the  whole  illness  lasting  twelve  to  seventeen  days,  and 
then  recovery  being  established.  Sometimes  even  less  time  elapses 
before  the  fever  ceases  and  the  patient  is  manifestly  convalescing. 

Then,  again,  the  abortive  type  of  this  fever  presents  itself,  in 
which,  after  an  illness  beginning  with  quite  characteristic  manifes- 
tations, often  of  considerable  severity,  the  symptoms  rapidly 
ameliorate,  and  convalescence  is  established  within  ten  days  of  the 
onset.  This  is  well  illustrated  by  the  following  temperature  chart 
of  a  student  recently  under  my  care.  On  March  8th  he  first 
began  to  suffer  from  symptoms  which  were  severe  enough  to  make 
him  seek  medical  aid  and  go  to  bed.  Prior  to  this  date  he  had 
felt  but  slightly  unwell  and  this  only  for  a  few  days.     As  is  seen 


VARIETIES  OF  ONSET. 


39 


in  the  chart,  his  temperature  fell  by  crisis  on  the  seventh  day  of 
his  illness,  although  the  positive  Widal  reaction  endorsed  the 
diagnosis  of  true  typhoid  fever.  Curiously  enough,  such  cases  are 
often  ushered  in  suddenly  by  marked  signs — high  fever  and  indi- 
cations of  grave  illness — and  yet  so  speedily  pass  on  to  the  fall 
by  lysis  that  it  seems  as  if  the  attack  must  be  due  to  some  other 
infection.  Such  cases  are  recorded  in  which  an  initial  fever  of 
106°  in  the  axilla  has  been  folloAved  by  a  normal  temperature  as 
early  as  the  seventh  day. 

Fig.  7. 


F       104° 

103° 

102° 
101° 
100° 
99  a 
98° 
97° 

Day  of  Dis. 

i 

1 

[ 

1 

l 

1 

I 

A 

1 

l 

1 

/ 

/ 

1 

h 

/ 

1 

/ 

f 

/ 

V 

1 

/ 

\ 

, 

/ 

sj 

I 

l 

1 

, 

\ 

/ 

~ 

N 

■7 

\ 

t 

\ 

^  I 

\ 

i  \ 

V 

5 

\ 

s 

s 

vd 

^n 

A 

\ 

/ 

\ 

A 

'  \ 

v 

\ 

1 

\ 

\ 

CO 

" 

» 

S3 

- 

CO 

a 

o 

c-t 

Abortive  typhoid  fever  ending  by  the  seventh  day,  and  by  crisis  instead  of  lysis. 

In  the  malignant  forms  of  infection  the  symptoms  of  onset 
may  be  of  three  types,  viz.,  mild,  followed  by  symptoms  of  increas- 
ing severity  ;  severe,  with  rapidly  fatal  developments,  and,  finally, 
aberrant  symptoms  pointing  rather  to  the  cranial  contents,  tho- 
racic organs,  or  other  parts  of  the  body  than  to  the  abdominal 
contents.  These  various  types  will  be  found  fully  discussed  in 
the  following  pages,  but  as  an  illustration  of  the  cerebral  type,  a  case 
reported  by  Green'   may  be  cited.      A  child  aged  four  years,  had 


1   Australian  Medical  Gazette  for  August  2\\   IS1.),. 


40       COMPLICATIONS  AND  SEQUEL M  OF  TYPHOID  FEVER. 

been  quite  well  until  four  days  before  admission,  when  he  was 
seized  with  an  attack  of  giddiness  while  playing,  turned  around 
and  around,  and  fell ;  but  there  was  no  loss  of  consciousness 
and  no  convulsive  movements.  Two  hours  later  he  vomited. 
There  was  no  ear  trouble.  A  week  later,  the  seventh  day  of 
the  attack,  the  child  had  a  convulsion,  lasting  two  minutes, 
which  affected  both  sides  of  the  body,  and  again  on  the  eleventh 
day  of  his  illness  he  had  a  very  severe  convulsion,  lasting  two 
hours,  affecting  both  sides,  although  after  it  passed  off  there  was 
marked  twitching  of  the  right  side  and  conjugate  deviation  of  the 
eyes  to  the  right.  The  next  day  hemiplegia  affecting  the  right 
side  was  well  developed.  The  convulsions  proceeded  off  and  on 
for  two  days,  affecting  only  the  right  side.  Afterward  vomiting 
became  a  constant  symptom,  and  death  occurred  on  the  thirtieth 
day  of  illness  and  nineteen  days  after  the  first  severe  convulsion. 
At  the  autopsy  a  large  portion  of  the  temporo-sphenoidal  lobe  of 
the  left  side  was  discovered  to  be  quite  soft  and  pulpy,  and  on 
making  a  transverse  section  of  this  area  the  softening  was  found 
to  affect  the  lenticular  nucleus  and  to  abut  very  closely  to  the 
anterior  horn  of  the  internal  capsule.  There  was  no  hemorrhage, 
but  the  left  middle  cerebral  artery  was  filled  with  a  blood-clot. 

When  it  is  possible  for  a  disease  to  present  such  widely  various 
symptoms  as  have  just  been  detailed,  in  its  early  stages,  and 
when  we  are  told  by  Liebermeister  that  "  there  is  not  a  single 
symptom  belonging  to  typhoid  fever  that  is  pathognomonic,"  it 
is  evident  that  errors  in  diagnosis  must  occur  even  in  the  most 
skilful  hands. 

Temperature  Variations  from  the  Usual  in  Onset.  Leaving 
the  general  consideration  of  the  types  of  onset  for  a  discussion 
of  the  individual  symptoms  of  this  period,  we  may  take  up  the 
question  of  the  range  of  temperature.  The  normal  variation  or 
character  of  the  fever  of  onset  has  already  been  described  in  the 
preceding  pages,  but  marked  variations  from  that  course  are  often 
present. 

In  this  connection  Dreschfeld  quotes  with  approval  a  state- 
ment of  Wunderlich's,  which  seems  to  the  writer  entirely  too  dog- 


VARIETIES  OF  ONSET.  41 

matic,  in  regard  to  the  character  of  the  oncoming  fever,  and  it  is 
certainly  entirely  at  variance  with  more  recent  observations.  I 
quote  it  to  illustrate  the  older  view  of  the  disease  :  "Any  fever 
which  on  the  second  day  reaches  to  104°  F.  is  not  enteric  fever,  nor 
is  it  enteric  if  the  fever  does  not  approach  104°  F.  on  the  evening 
of  the  fourth  day  ;  on  the  other  hand,  enteric  fever  may  be  diag- 
nosed if  in  a  middle-aged  person  suffering  from  an  acute  febrile 
attack  the  evening  temperature  on  the  fifth  day,  or  within  the  first 
week,  is  between  103°  and  105°,  and  alternates  with  morning  tem- 
peratures, which  are  1.4°  to  1.7°  lower,  unless  some  other  disorder 
can  be  discovered  to  explain  the  height  of  the  fever.  It  is  well 
to  state  that  by  morning  temperature  we  mean  the  temperature 
about  9  a.m.  ;  by  evening  temperature  that  about  6  p.m."  These 
views  certainly  do  not  hold  true  to-day  for  the  ordinary  types  of 
the  disease.  Attention  has  already  been  called  to  the  very  low 
temperature  seen  in  the  mild  forms  of  the  disease  and  to  the  high 
fever  sometimes  met  with  even  in  the  so-called  abortive  cases. 

During  the  stage  of  onset  variations  in  the  temperature  of  the 
patient  may  be  due  to  complicating  states  which  are  about  to  be 
described,  or  they  are  perversions  of  the  ordinary  temperature  of 
the  initial  days,  occurring  without  assignable  cause.  The  presence 
of  a  consolidation  in  the  lung,  of  a  pleurisy,  or  of  a  serious 
lesion  in  any  one  of  the  organs  of  the  body,  may  entirely  alter 
the  chart  in  this  period  of  the  malady  ;  and  predominant  local- 
ized symptoms  may  still  further  mask  the  case. 

This  is  well  shown  by  the  following  case  recorded  by  Morris.1 
Aside  from  its  obscure  mode  of  onset  this  case  is  also  of  interest 
since,  as  a  rule,  hepatic  infection  manifests  itself  after  an  attack 
of  typhoid  fever  rather  than  before  : 

On  September  21,  1898,  he  was  called  in  consultation  by  Dr.  R. 
E.  Doran,  of  Willard  State  Hospital,  to  see  Mr.  J.  L.  B.,  twenty- 
six  years  of  age,  who  had  been  suddenly  seized  forty-eight  hours 
previously,  with  a  sharp  pain  below  the  right  inferior  costal  mar- 
gins, which  rapidly  extended  as  an  acute  general   peritonitis,  with 

1  New  York  Medical  Journal,  January  28,  1899. 


42       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

a  temperature  reaching  102°  Fv  but  apparently  without  accom- 
panying rigors.  The  patient  was  constipated  until  the  day  on 
which  Dr.  Morris  arrived.  On  examination  a  mass  was  easily 
palpated  at  the  site  of  the  gall-bladder,  and  the  peritonitis  seemed 
to  be  most  intense  at  that  point.  They  diagnosticated  empyema 
of  the  gall-bladder  and  operated.  The  peritoneum  was  deeply 
congested  and  was  covered  with  coagulated  lymph  in  the  vicinity 
of  the  gall-bladder.  The  gall-bladder  was  distended  with  a  mix- 
ture of  thin,  greenish  mucus  and  thick,  tenacious  yellow  pus.  Dr. 
Morris  did  not  have  his  culture-tubes  at  hand,  and  no  bacterio- 
logical examination  of  the  pus  was  obtained,  much  to  his  regret. 
He  drained  the  wound  and  the  gall-bladder  with  a  small  wick 
drain  and  closed  the  incision,  excepting  for  the  drainage  opening. 
On  the  evening  of  the  day  of  operation  the  temperature  rose  to 
103°  F.  and  dropped  on  the  following  morning  to  100°  F. ;  the 
pulse  to  88  ;  the  respirations  to  24.  On  the  evening  of  the  second 
day  after  operation  the  temperature  rose  to  106°  F.  Up  to  this 
time  the  bowels  had  not  moved,  but  two  high  enemata  of  Epsom 
salts  caused  a  number  of  loose  movements,  and  the  symptoms  of 
dangerously  progressive  infection  subsided  rapidly.  After  this  the 
symptoms  of  typhoid  fever  supervened,  and  the  case  ran  a  typical 
course  as  one  of  typhoid  fever,  ending  in  recovery  in  about  four 
weeks,  excepting  for  a  small  biliary  fistula,  which  was  closing 
spontaneously  at  last  reports  from  Dr.  Doran. 

In  nervous  children  or  women  the  irritation  of  the  heat  centres 
often  results  in  a  sudden  rise  like  that  which  is  met  with  in  the 
more  acute  maladies  of  an  infectious  type.  And  it  is  a  well-known 
fact  that  typhoid  fever  in  children  is  more  apt  to  be  ushered  in  by 
a  chill  and  high  fever  than  it  is  in  adults,  as  has  been  well  pointed 
out  by  Jacobi  and  J.  Lewis  Smith.  A  case  of  this  character  is 
reported  by  Guinon,1  in  which  a  child  of  two  and  one-half  years 
was  seized  with  high  fever  and  with  all  the  symptoms  of  pernicious 
malarial  infection.  Nine  days  later  it  suffered  from  collapse  with 
all  its  characteristic  symptoms,  and  the  day  following  passed  stools 

1  Revue  Mensuelle  des  Maladies  l'Enfance,  1897,  p.  236. 


VARIETIES  OF  ONSET.  43 

which  were  typhoid  in  appearance.  Collapse  again  occurred,  and 
on  the  twelfth  day  symptoms  of  meningitis  developed.  Finally, 
arose  rash  appeared,  the  spleen  and  liver  were  found  to  be  en- 
larged, and  the  case  proved  itself  to  be  one  of  unmistakable 
typhoid  fever.  The  early  age  of  the  child,  the  sudden  onset,  the 
flushed  face,  the  high  fever,  the  collapse,  and,  finally,  the  menin- 
geal symptoms  are  of  interest. 

In  some  instances  in  which  high  temperature  is  noted  when 
the  physician  first  sees  the  patient,  it  is  not  in  reality  the  earliest 
perversion  of  normal  temperature  in  that  a  mild  and  unnoticed 
fever  has  been  present  for  some  days,  even  though  the  patient  has 
felt  perfectly  well. 

High  initial  temperatures  should  place  the  physician  on  his 
guard,  because  they  may  mean  severe  infection  or  some  grave 
complication  which  he  must  search  for  and  discover,  and  parti- 
cularly is  this  the  case  if  the  initial  temperature  is  ushered  in  or 
is  followed  bv  a  chill  or  rigor.  In  some  of  these  cases  careful 
study  of  the  history  of  the  patient  will  reveal  an  exposure  to 
malarial  infection,  and  an  examination  of  the  blood  may  reveal 
the  presence  of  the  malarial  parasite,  although,  as  pointed  out 
further  on,  this  organism  is  apt  to  be  absent  from  the  blood  dur- 
ing the  active  period  of  typhoid  fever. 

The  more  sudden  the  appearance  of  the  disease,  and  the  more 
rapid  the  rise  of  temperature  in  the  beginning  of  the  first  week,  so 
much  the  more  should  one  expect  in  general  a  short  and  even 
abortive  attack,  and  the  more  rapidly  the  temperature  falls,  as 
the  end  of  the  first  week  is  approached,  the  better  the  prognosis, 
particularly  if  the  daily  fluctuations  are  marked. 

Very  sudden  development  of  true  hyperpyrexia  at  this  stage, 
unless  it  is  due  to  some  severe  complication,  is  very  rare. 

Chills.  In  some  instances,  not  commonly  met  with,  typhoid 
fever  is  ushered  in  by  severe  chills.  As  already  pointed  out, 
these  arc  most  apt  to  appear  in  children,  and  they  may  indi- 
cate the  development  of  some  coincident  infection.  ( 'hills  may, 
however,  be  due  to  the  typhoid  infection  itself.  They  are  met  with 
more  frequently  at  the  onset   of  a   relapse   than    at  the  primary 


44       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

onset.  In  a  case  recently  under  the  writer's  care,  a  man  of  thirty- 
five  years,  after  several  days  of  malaise,  without  fever,  was  seized 
with  a  violent  rigor  and  at  once  became  so  ill  that  he  was  forced 
to  go  to  bed,  where  he  passed  through  a  severe  attack  of  the  disease. 
Under  the  name  of  "  sudoral  typhoid  fever,"  Jaccoud  records, 
in  La  Semaine  IlSdicale  for  March  12,  1897,  his  belief  in  this 
special  type,  in  which  chills  and  sweats  are  prominent  symp- 
toms. The  onset  of  the  malady  is  sudden,  and  is  accompanied 
by  severe  headache  in  the  retro-orbital  and  occipital  regions 
with  shivering,  fever,  and  sweats,  so  that  the  patient  resembles 
one  suffering  from  an  intermittent  malarial  attack.  These 
attacks  are  often  quotidian  and  the  febrile  movement  is  hyperpy- 
retic.  The  peculiar  symptoms  cease  by  the  fifth  day,  and  are 
followed  by  the  usual  course  of  typhoid  fever.  Quinine  does  no 
good  in  these  cases,  and  they  are  not  due  to  malarial  infection. 
A  second  form  is  characterized  by  the  primary  appearance  of  head- 
ache and  fever  followed  by  sweating,  which  is  profuse  and  asserts 
itself  much  later  than  in  the  form  just  described.  The  febrile 
movement  is  distinctly  intermittent  in  type,  but  not  so  markedly 
so  as  in  the  form  just  named.  In  other  cases,  in  place  of  a  marked 
rigor,  the  patient  has  a  subjective  sensation  of  coldness  in  some 
part  of  the  body,  which  can  also  be  perceived  by  the  physician  if 
he  touches  the  spot.  In  these  forms  the  irregular  manifestations 
may  last  three  weeks  and  then  gradually  cease  in  the  fourth  week. 
Sometimes  these  cases  are,  however,  very  prolonged,  and  Borelli 
has  reported  instances  lasting  seventy  or  ninety  days.  Indeed, 
Jaccoud  regards  the  length  of  the  attack  as  characteristic.  There 
are  practically  no  complications.  Albuminuria  is  extremely  rare, 
but  intestinal  hemorrhage  of  mild  degree  is  not  uncommon.  Peri- 
tonitis from  perforation,  Jaccoud  asserts,  is  quite  unknown  in  these 
forms,  and  he  regards  "  sudoral  typhoid  fever"  as  a  mild  type  of 
the  disease.  Notwithstanding  the  close  resemblance  of  these  types 
to  double  infection  by  the  malarial  organism  and  the  typhoid 
bacillus,  both  Jaccoud  and  Borelli  believe  them  to  be  pure  typhoid 
fever,  because  they  occur  in  persons  who  have  never  been  exposed 
to  malarial  infection,  and  because  quinine  is  useless. 


VARIETIES  OF  ONSET.  45 

The  differential  diagnosis  is  necessarily  difficult  in  the  early 
stages  of  the  disease,  although  in  general  Jaccoud  would  have  us 
believe  that  it  is  easy.  It  must  depend  largely  upon  the  absence 
of  any  history  of  malarial  exposure,  upon  complete  development 
of  most  of  the  characteristic  signs  of  typhoid  fever,  and,  finally, 
upon  the  absence  of  any  signs  of  the  malarial  organism  in  the 
blood  and  the  presence  of  the  Widal  reaction.  In  cases  of  "  abor- 
tive sudoral  typhoid  fever,"  in  which  the  disease  runs  a  very 
short  course  and  stops  abruptly,  the  diagnosis  is  very  difficult. 
Jaccoud  describes  such  a  case  as  follows  : 

"  In  the  patient  referred  to  the  headache  and  the  temperature 
chart  justified  the  diagnosis  of  mild  typhoid  fever,  but  the  diges- 
tive organs  were  intact ;  there  was  no  abdominal  tympanism  and 
no  diarrhoea.  The  spleen  was  of  perfectly  normal  size,  the  tongue 
a  little  dry,  but  otherwise  showed  absolutely  none  of  the  char- 
acteristics of  typhoid  fever.  There  was  absolutely  nothing  in  the 
lungs.  The  fever  alone,  and  the  slightly  stupefied  appearance  of 
the  patient,  led  us  to  assume  the  existence  of  some  typhoid  infec- 
tion. There  also  existed  on  his  body  a  measly  eruption  ;  but  this 
was  a  superadded  element,  due  probably  to  the  large  doses  of  anti- 
pyrine  which  he  had  taken,  and  also  to  some  alcoholic  frictions 
which  had  been  given.  Beside  he  was  a  grocer  by  trade,  and 
grocers  are  specially  exposed  to  skin  irritations  which  not  infre- 
quently give  rise  to  cutaneous  affections.  On  the  first  days  he 
had  presented  a  certain  degree  of  ocular  catarrh,  with  redness  of 
the  conjunctiva  and  watery  eyes.  Then  abundant  perspiration 
appeared  on  the  forehead,  the  nose,  and  the  chest,  drenching  those 
parts  completely.  The  fever  developed  in  this  way  for  ten  days, 
the  headache  was  general  and  persistent,  but  not  very  intense,  and 
during  the  whole  of  this  time  there  was  nothing  worthy  of  note, 
except  the  hypersudation  and  the  rubeolar  eruption. 

"The  case  was  evidently  one  of  abortive  typhoid  fever  of  the 
sudoral  variety,  and  could  be  classed  in  the  mixed  form  which  I 
have  described.  There  was  one  abnormal  point,  viz.,  the  subsi- 
dence of  the  fever,  which  was  complete  on  (he  tenth  day.  Such 
rapid  termination,  not  very  unusual  in  ordinary  typhoid  fever,  is. 


46       COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER. 

I  repeat,  almost  exceptional  in  sudoral  typhoid.  The  differential 
diagnosis  between  sudoral  typhoid  and  malaria — L  e.,  typho-mala- 
ria,  is,  on  the  whole,  easy,  and  hesitation  between  the  two  cannot 
last  long,  the  administration  of  quinine  salts,  which  are  without 
action  on  sudoral  typhoid,  settles  the  question." 

The  violent  headache  of  so-called  sudoral  typhoid  fever,  which 
is  sometimes  the  only  prodrome,  may  lead  one  to  think  of  influ- 
enza, and  in  particular  of  the  nervous  form  of  that  disease ;  but 
in  influenza  the  pain  is  not  localized  in  the  head  alone.  It  ap- 
pears early  and  is  very  intense,  but  is  also  general  all  over  the 
body;  the  temperature  may  remain  normal,  or,  if  there  is  fever, 
the  temperature-curve  is  totally  different  from  that  of  typhoid 
fever.  The  evolution  of  the  influenza  itself,  which  is  in  general 
of  short  duration  when  it  remains  uncomplicated,  helps  considera- 
bly in  the  differential  diagnosis. 

One  might  be  misled  into  diagnosing  measles  when,  along  with 
the  ocular  catarrh,  there  is  a  discrete  eruption  of  rose-colored 
spots,  or  else  a  true  roseolar  eruption  like  that  of  the  patient 
under  consideration.  The  absence,  however,  of  all  eruption  on 
the  face  and  neck,  of  broncho-pulmonary  catarrh,  the  insignifi- 
cance of  the  ocular  catarrh,  and  the  character  of  the  temperature 
chart,  all  enable  us,  Jaccoud  thinks,  to  eliminate  this  hypothesis 
without  much  difficulty. 

The  writer  has  had  under  his  care  during  the  winter,  1898-99, 
a  case  which  followed  this  course  : 

A  man  of  twenty-five  years,  a  cigarmaker  by  occupation,  was 
taken  ill  with  what  was  supposed  to  be  "  malaria  "  or  "  grippe  "' 
on  February  4th,  but  felt  better  and  returned  to  work  on  the  6th. 
On  the  7th  he  felt  very  ill,  and  entered  my  wards  on  the  8th. 
At  this  time  he  had  marked  swelling,  as  if  from  a  phlebitis,  of  the 
left  leg,  which  entirely  disappeared  in  twenty-four  hours.  He 
presented  all  the  characteristic  symptoms  of  ordinary  typhoid 
fever  by  the  tenth  day  of  the  disease,  but  his  temperature  made 
the  following  extraordinary  chart,  each  rise  being  followed  by 
profuse  sweating.  He  also  had  profuse  night-sweats.  He  never 
had  typhoid  fever  before,  nor  were  there  any  signs  of  tuberculosis 


VARIETIES  OF  ONSET. 


47 


or  ulcerative  endocarditis.  His  blood  showed  no  signs  of  the 
malarial  organism  and  gave  the  Widal  reaction  on  the  thirteenth 
day. 

Fig.  8. 


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To  save  space  this  chart  which  showed  in  detail  rigor  after  rigor  and  fever 
after  fever,  has  been  reduced  to  a  morning  and  evening  chart,  and,  therefore, 
only  shows  two  or  three  paroxysms. 

(For  a  discussion  of  so-called  typho-malarial  fever  and  of  malaria 
complicating  typhoid  fever,  see  chapter  on  the  fever  in  the  well- 
developed  stage  of  the  disease,  and  that  on  other  diseases  which 
ape  typhoid  fever.) 

Respiratory  Conditions  in  Onset.  Several  eases  have  im- 
pressed upon  me  the  fact  that  so-called  "  pneumo-typhoid  fever" 
is  a  more  common  state  than  is  generally  thought,  although  it  is 
true  the  standard  text-hooks  all  describe  this  form  of  the  disease. 
By  pneumo-typhoid  fever  I  refer  to  that  form  of  typhoid  fever 
iu   which   the  bacillus  of   Eberth  exercises  its  primary  influence 


48       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

upon  the  pulmonary  parenchyma,  producing  signs  and  symptoms 
which  are  practically  identical  with  those  of  ordinary  croupous 
pneumonia,  even  to  the  rusty  sputum,  although  the  usual  rigor  of 
onset,  as  seen  in  true  croupous  pneumonia  may  be  absent  or  modi- 
fied, and  the  onset  in  general  is  more  insidious.  In  these  cases 
toward  the  ninth  or  tenth  day  the  high  fever  falls  but  slightly  in 
place  of  the  characteristic  crisis,  and  when  diarrhoea  and  rose  spots 
appear,  the  possibility  of  the  entire  illness  being  due  to  a  typhoid 
infection  comes  upon  the  mind  of  even  the  careful  physician  for 
the  first  time.  This  condition  must  not  be  confused  with  the  so- 
called  tvphoid-pneumonia  in  which  there  is  a  double  infection  of 
the  patient,  his  lung  bearing  the  chief  influence  of  the  micrococcus 
lanceolatus  and  his  intestinal  canal  and  general  system  that  of  the 
bacillus  of  Eberth,  nor  the  state  in  which  the  pulmonary  consoli- 
dation results  from  asthenia  or  other  causes  incidental  to  the  prog- 
ress of  an  exhausting  malady,  and  which  is  usually  a  catarrhal 
pneumonia  or  a  congestion  by  stasis.  As  Osier  has  well  said, 
"  typhoid  fever  is  a  multiple  infection  in  which  the  chief  lesion 
of  the  disease  may  be  found  in  other  organs  than  the  bowels,"  and, 
in  a  larger  number  of  cases  than  is  thought,  pneumonia  begins  the 
attack  of  illness,  and  only  later  on  does  the  character  of  the  specific 
infection  make  itself  manifest.  The  following  case  illustrates  this 
fact  very  well,  and  is  one  of  a  number  which  have  been  met  with 
by  the  author  : 

Z.,  a  girl,  aged  ten  years,  was  taken  ill  with  a  rigor  and  fever 
on  November  10th,  having  been  well  enough  to  be  up  and  out  of 
doors  at  dancing-school  the  day  before.  The  fever  speedily  rose  to 
points  ranging  from  103°  to  105°,  and  remained  about  these  points 
for  the  first  few  days,  when  it  gradually  became  a  little  less  marked. 
It  failed  to  respond  readily  to  the  use  of  cold  spongings  and  the 
cold  sheet,  as  a  rule,  although  at  times  this  treatment  reduced  it 
considerably.  There  was  but  little  cough,  and  at  times  none  of  it 
for  two  or  three  days,  but  the  child  was  somewhat  dyspnoeic,  par- 
ticularly at  night,  and  cyanosis  was  marked.  The  pulse  was 
usually  as  high  as  120  to  130,  and  restlessness  was  constant,  At 
times,  particularly  at  night,  there  was  delirium.     An  examination 


VARIETIES  OF  ONSET.  49 

of  her  chest  revealed  at  the  right  middle  lobe  the  physical  signs 
of  consolidation — that  is,  bronchial  breathing,  dnlness  on  percus- 
sion, and  absence  of  vesicular  sounds,  with  exaggerated  breathing 
elsewhere.  At  the  left  apex  similar  signs  were  present,  and  it  was 
evident  that  the  child  had  pneumonia.  The  facial  expression,  the 
somewhat  dry  lips  and  tongue,  and  the  color  of  the  patient's  skin, 
combined  with  the  fact  that  pneumonia  sometimes  is  due  to  infec- 
tion by  the  bacillus  of  Eberth,  made  Dr.  Kirkpatrick,  the  physi- 
cian who  courteously  called  me  in  consultation,  and  myself  caution- 
as  to  the  diagnosis  and  the  prognosis  of  the  case,  and,  equally 
important,  careful  as  to  our  treatment.  The  parents  were  told  of 
the  condition  of  the  lung  and  of  our  suspicion  that  something 
other  than  a  pure  pneumonic  infection  was  present,  and  we  waited 
for  the  day  of  ordinary  crisis  with  anxiety.  On  the  ninth  the 
temperature  fell  somewhat  and  seemed  to  give  promise  of  relief, 
but  on  the  next  day  it  maintained  its  course ;  the  tongue  was 
found  to  be  more  enteric  in  appearance,  and  the  rose  rash  of 
typhoid  fever  appeared  on  the  chest  and  belly.  Further,  careful 
palpation  and  percussion  at  this  time  showed  a  slightly  enlarged 
spleen  and  liver,  an  alteration  in  those  organs  not  previously 
found,  and  diarrhoea,  or,  rather,  looseness  of  the  bowels,  sup- 
planted a  tendency  to  constipation. 

Under  our  older  ideas  of  these  diseases  it  would  have  been 
thought  that  a  primary  croupous  pneumonia  had  merged  into  a 
typhoid  fever  by  a  gradual  process  of  developing  asthenia,  or, 
again,  that  a  double  infection  with  the  micrococcus  lanceolatus 
and  the  bacillus  of  Eberth  had  taken  place,  whereas,  at  the  present 
time  we  know  that  while  such  a  double  infection  is  possible,  a 
single  typhoid  fever  infection  may  result  in  primary  pulmonary 
symptoms. 

Still  another  case  is  that  of  B.,  a  man  of  sixty-five  years,  who 
was  taken  ill  with  general  malaise  and  wretchedness  on  a  certain 
Friday.  Fever  and  chilly  sensations  developed,  but  he  kept  on 
his  feet  for  two  days,  when  he  was  so  ill  that  he  had  to  go  to  bid. 
When  seen  by  me  in  consultation  on  the  fourth  day  of  his  illness 
there  was  rapid   respiration  (42  per  minute),  a  pulse-rate  of  120, 

4 


50       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

some  cyanosis,  a  feeble,  painful  cough,  and  consolidation  of  the 
entire  lower  lobe  of  the  right  side,  with  exaggerated  breathing  on 
the  left  side  of  the  chest.  His  temperature  rose  from  102°  to 
103°,  and  the  bowels  were  costive  to  a  marked  degree.  The  spu- 
tum was  rusty.  A  diagnosis  of  croupous  pneumonia  was  made, 
and  not  until  the  tenth  day  of  his  illness  did  a  persistent  diarrhoea 
of  ochre-colored  stools,  with  spots,  appear.  The  spleen  had  been 
found  enlarged  from  the  first  visit  that  I  paid  him. 

The  difficulty  in  diagnosing  these  cases  lies  in  the  distinctly 
local  manifestations  and  the  fact  that  in  some  patients  the  fever 
may  be  quite  high,  delirium  of  an  active  form  may  be  marked, 
and  every  symptom  pointing  to  intestinal  typhoid  lesions  may  be 
absent.  The  question  naturally  arises  as  to  the  frequency  with 
which  this  form  of  enteric  fever  occurs,  but  statistics  concerning 
it  are  difficult  to  collect,  since  in  many  instances  the  condition  is 
never  recognized,  or  is  recognized  very  late,  and  is  not  by  any 
means  always  reported. 

There  is  danger  in  these  cases  of  still  another  error  in  diagnosis, 
and  care  must  be  exercised  that  a  diagnosis  of  "  pneumo-typhoid  " 
is  not  made,  when  in  reality  the  condition  is  one  of  tuberculosis 
of  the  lung,  for  in  some  cases  of  this  character  the  rapid  onset  of 
fever,  rigor,  quickened  respiration,  cough,  and  the  development  of 
physical  signs  of  consolidation,  coupled  with  the  continuance  of 
fever  after  the  time  for  ordinary  crisis,  will  show  that  the  disease 
is  not  croupous  pneumonia.  As  a  matter  of  fact,  the  cases  of 
acute  tubercular  pulmonary  consolidation  simulating  pneumonia  at 
first  or  "pneumo-typhoid"  afterward,  are  much  more  frequent 
than  is  pneumo-typhoid  itself,  and  careful  study  of  the  case  itself, 
or  its  history,  and  the  microscopical  examination  of  the  sputum 
may  reveal  the  tubercular  character  of  the  process.  In  all  cases  of 
suspected  pulmonary  tuberculosis,  however,  the  absence  of  bacilli 
from  the  sputum  will  not  negative  the  diagnosis  of  this  malady, 
for  until  some  tissue  breakdown  occurs  the  bacilli  may  not  appear 
in  the  sputum. 

It  has  already  been  pointed  out  that  there  is  a  form  of  pneumonia 
ushering  in  typhoid  fever  quite  different  in  cause  from  that  just 


VARIETIES  OF  ONSET.  51 

named,  namely,  that  due  to  double  infection  with  the  specific 
organism  of  croupous  pneumonia  and  that  of  typhoid  fever.  Such 
cases  have  been  described  particularly  by  Chantemesse.  In  such 
instances  the  febrile  movement  of  the  pneumonia  merges  into  that 
of  enteric  fever.  The  early  differential  diagnosis  of  these  two 
conditions  is  practically  impossible  unless,  perchance,  the  bacillus 
of  Eberth  is  found  in  the  feces,  which  is  not  possible  before  the 
ninth  day,  or  the  Widal  test  gives  a  positive  reaction,  which  it 
rarely  does  in  the  early  days  of  the  malady. 

Acute  pleurisy,  like  acute  pneumonia,  may  usher  in  enteric 
fever,  this  condition  being  due  to  the  ordinary  causes  of  pleurisy 
being  present  simultaneously  with  typhoid-fever  infection,  or  be- 
cause of  specific  infection  of  the  pleura  by  the  typhoid  bacillus. 
Thus  Talamon1  has  recorded  a  case  of  enteric  fever  in  which  the 
onset  was  characterized  by  acute  pleurisy,  but  the  condition  differed 
from  that  ordinarily  seen  in  this  affection  by  reason  of  the  intensity 
and  persistency  of  the  fever,  and  by  the  general  depression  and 
sleeplessness,  headache,  and  vertigo. 

Talamon  insists  that  there  is  a  distinct  difference  to  be  noted 
between  pleural-typhoid  and  acute  febrile  pleurisy,  for  in  the 
typhoidal  infection  the  symptoms  are  out  of  all  proportion  to  the 
physical  signs.  The  only  condition  which  may  closely  resemble 
pleuro-tvphoid  is  tuberculous  pleurisy,  but  in  tuberculous  pleurisy 
the  temperature  is  remittent,  whereas  that  of  typhoid  is  rarely  so. 
Finally,  the  development  of  the  other  symptoms  of  typhoid  will 
clear  up  the  diagnosis. 

A  very  much  more  rare  respiratory  disorder  which  may  usher 
in  typhoid  fever  is  that  chain  of  symptoms  known  as  laryngo- 
typhoid,  in  which  great  hoarseness  or  aphonia  develops  with  dis- 
tinct evidence  of  acute  laryngitis.  These  cases  are  quite  differ- 
ent from  those  of  severe  ulcerating  laryngitis  seen  in  advanced 
stages  of  the  disease,  and  which  will  be  considered  later  on  in 
the  chapters  on  the  well-developed  and  convalescing  stages  of  the 
disease.     Such  instances  are  well  illustrated  by  a  patient  described 

1  La  Medicine  Moderne,  May  28,  1892. 


52       COMPLICATIONS  AND  SEQUEL M  OF  TYPHOID  FEVER. 

by  Bayer.1  A  physician  presented  himself  for  treatment  because 
of  aphonia  and  difficulty  in  swallowing,  which  was  found  to  be 
due  to  acute  laryngo-pharyngitis.  These  local  symptoms  were 
improved  by  treatment,  but  in  a  few  days  the  man  was  seized  with 
a  severe  chill,  followed  by  fever  and  pain  in  the  throat,  an  exami- 
nation of  which  revealed  a  number  of  small  superficial  ulcers  on  the 
soft  palate  and  on  the  pharynx  ;  later  the  characteristic  rose  spots 
appeared  on  the  skin.  More  interesting  than  all,  particles  of  tissue 
removed  from  the  heads  of  the  ulcers  just  named  contained  the 
bacillus  of  Eberth.  The  inflammation  extended  to  the  ears,  and 
deafness  resulted.  The  patient  finally  died  from  intestinal  hemor- 
rhage and  pneumonia.  The  finding  of  the  bacillus  in  such  cases 
would  enable  an  early  diagnosis  to  be  made. 

Almost  equally  rarely  does  a  severe  bronchitis  usher  in  typhoid 
fever  as  a  true  pulmonary  or  primary  manifestation,  although,  as 
the  disease  progresses,  more  or  less  bronchial  inflammation  is 
usually  found. 

Symptoms  of  Onset  in  the  Kidneys.  In  very  rare  instances 
typhoid  fever  develops  with  marked  evidences  of  acute  nephritis, 
the  urine  being  smoky  or  bloody  in  appearance,  and  containing 
albumin  and  casts.  This  form  is  sometimes  called  "  nephro- 
typhoid,"  and  by  the  French  "fievre  typlioide,  a  forme  r&nale" 

Gaillard2  recently  reported  to  the  Societe  M6dicale  des  Hopi- 
taux,  for  Bagot,  the  following  interesting  case  of  hsematuria  usher- 
ing in  typhoid  fever.  The  patient  was  a  lad  of  ten  and  one-half 
years,  who  was  taken  ill  on  June  28th  with  hematuria.  On  July 
3d  the  patient  suffered  from  a  good  deal  of  tenesmus,  pain  in  the 
urethra,  and  the  urine  contained  red  blood-cells  but  no  casts.  On 
July  7th  distinct  febrile  movement  was  noted,  the  child  com- 
plained of  severe  lumbar  pains,  which  also  extended  into  the 
limbs.  He  then  passed  through  a  typical  attack  of  typhoid  fever, 
reaching  a  normal  temperature  on  July  26  th,  nearly  a  month  after 
the  onset  of  his  attack.  The  urine  contained  no  blood  after  the 
eighteenth  day  of  his  illness.    Bagot  asserts  that  there  is  no  doubt 

1  Revue  de  Laryngologie,  d'Otologie  et  de  Rhinologie,  July  15,  1893. 

2  La  Presse  M<5dicale,  February  11,  1899. 


VARIETIES  OF  ONSET.  53 

whatever  about  the  correctness  of  the  diagnosis.  That  this  patient 
had  a  distinct  tendency  to  hematuria  seems  indicated,  however, 
by  the  fact  that  in  subsequent  illnesses,  other  than  that  due  to  the 
typhoid  infection,  he  also  suffered  from  this  condition  of  hema- 
turia.     (For  further  remarks  see  later  chapters.) 

Retention  of  urine  is  sometimes  met  with  in  the  early  stages 
of  typhoid  fever  but  usually  passes  away  in  a  few  days. 

Symptoms  of  Onset  in  the  Alimentary  Tract.  Tonsillar 
inflammation,  associated  with  severe  pharyngitis,  sometimes  begins 
the  course  of  enteric  fever,  and  escapes  correct  diagnosis  as  to  its 
cause  for  a  considerable  period  of  time  because  of  the  situation  of 
the  lesions,  and  also  because  tonsillitis  of  an  active  form  is  so  com- 
monly associated  with  marked  evidences  of  general  systemic  infec- 
tion, the  patient  oftentimes  appearing  profoundly  ill  and  suffering 
from  general  wretchedness,  febrile  movement,  a  heavily  coated 
tongue,  impaired  hearing,  and  mental  hebetude. 

A  case  of  this  character  is  under  my  care  in  private  practice  at 
the  present  time.  A  woman  of  thirty  years  was  taken  ill  with 
what  appeared  to  be  a  severe  attack  of  acute  tonsillitis  with  high 
fever.  As  the  fever  failed  to  disappear  with  the  subsidence  of 
the  tonsillar  swelling  and  pain,  and  as  an  epidemic  of  typhoid 
fever  was  present,  her  blood  was  examined  for  the  Widal  reaction, 
and  it  was  found,  and  simultaneously  other  symptoms  of  enteric 
fever  developed. 

A  peculiar  form  of  ulceration  of  the  pharynx  has  been  recorded 
by  Bouveret,1  Devignac,  Dengnet,  Wagner,  and  Calm.  They  call 
it  "  pharyngo-typhoid."  The  ulcers  are  superficial,  clean-cut,  and 
appear  chiefly  on  the  soft  palate.      (See  also  later  chapters. ) 

(For  oesophageal  lesions  see  the  next  chapter.) 

Probably  the  most  common  perversions  of  the  early  manifes- 
tations of  enteric  fever  are  to  be  found  in  association  with  the 
functions  of  the  gastro-intestinal  tract.  So  common  are  they,  and 
so  localized  are  the  dominant  symptoms  in  these  cases,  that  the 
malady  seems  quite  distinct  from  true  typhoid  fever,  and  is  often 

1  Berliner  klin.  Wochenschrift,  1885,  No.  It. 


54       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

called  the  gastric  form  of  typhoid  fever.  In  some  instances,  it  is 
true,  fever  of  mild  degree  develops  in  cases  of  gastric  catarrh  of  a 
more  or  less  severe  form,  but  they  are  not  characterized  by  the  pro- 
found degree  of  illness  seen  in  the  gastric  type  of  enteric  fever,  in 
which  persistent  vomiting  and  epigastric  disturbance  followed  by 
diarrhoea  are  the  main  symptoms  in  the  early  or  initial  stages. 
Such  gastric  types  are  more  commonly  met  with  in  children.  As 
well  pointed  out  by  Bristowe,  undoubted  enteric  fever  in  child- 
hood, at  which  age  recovery  commonly  occurs  even  if  the  disease 
is  overlooked,  is  often  called,  for  want  of  a  better  name  and  a 
certain  diagnosis,  by  the  conscience-quieting  term  of  "  infantile 
remittent  fever,"  "bilious  fever,"  and  "gastric  fever,"  or  even 
"  worm  fever."  (See  Frequency  of  Enteric  Fever  in  Childhood, 
in  Chapter  I.) 

The  gastric  manifestations  when  severe  are,  perhaps,  more  rap- 
idly discovered  to  be  due  to  enteric  fever  than  if  the  infection 
be  mild  when  the  other  typhoid  symptoms  are  not  marked. 
These  gastric  symptoms  are  rarely  met  with  in  the  great  cities  of  the 
eastern  part  of  the  United  States,  and  vary  in  different  epidemics, 
although  they  are  asserted  by  Murchison  to  have  been  commonly 
met  with  in  his  experience.  On  the  other  hand,  Hutchinson,  in 
his  classic  article  in  Pepper's  System  of  Medicine,  tells  us  that  these 
acute  gastric  symptoms  with  nausea  and  active  vomiting  have  been 
unusual  in  his  experience.  When  vomiting  ushers  in  the  disease 
in  a  child  it  does  not  seem  to  be  as  evil  a  prognostic  sign  as  when 
this  symptom  begins  the.  attack  in  an  adult.  I  saw  a  year  ago  a 
case,  in  consultation  with  Dr.  Orville  Horwitz,  in  which  persistent 
vomiting  was  the  first  sign  of  the  disease,  and  preceded  a  very 
severe  illness.  Vomiting  in  a  child  is  readily  produced  by  any 
disturbing  ailment,  but  in  an  adult  it  probably  results  from  a 
more  or  less  profound  infection,  and  rapidly  causes  exhaustion  if 
it  is  persistent,  as  it  is  apt  to  be  in  this  class  of  patients.  When 
the  vomiting  is  mild,  or,  in  other  words,  is  repeated  but  once  or 
twice,  it  is  not,  of  course,  of  any  gravity,  and  no  less  an  authority 
than  Murchison  intimates  that  such  cases  often  seem  to  be  bene- 
fited by  it  if  it  be  not  too  persistent. 


VARIETIES  OF  ONSET.  55 

A  severe  and  continued  vomiting  attack  in  a  case  free  from 
malaria  and  associated  with  persistent  febrile  movement  ought  to 
arouse  the  suspicion  of  typhoid  infection  to  a  sufficient  degree  to 
cause  the  physician  to  be  on  the  watch  for  further  confirmatory 
symptoms,  particularly  if  the  illness  is  not  relieved  by  the  ordinary 
measures  utilized  for  the  cure  of  such  an  illness. 

Another  variety  of  onset,  represented  by  disturbance  of  the 
gastro-intestinal  functions,  is  that  characterized  by  the  sudden 
development  of  violent  diarrhoea  of  the  serous  type,  instead  of 
the  constipation  usually  met  with  during  the  first  week  of  the 
disease.  Such  cases  are  not  common,  but  are  represented  by  the 
following  case  in  my  own  experience.  A  man  of  thirty -five  years, 
apparently  in  perfect  health,  and  whose  appetite  had  been  excel- 
lent up  to  and  including  the  morning  of  the  beginning  of  his 
illness,  began  to  suffer  after  a  moderately  heavy  luncheon  from 
slight  headache,  which  he  attributed  to  indigestion,  to  which  he 
was  subject.  He  ate  no  supper  because  of  nausea,  and  was  seized 
at  twelve  o'clock  midnight  with  an  active,  watery  diarrhoea, 
resembling  a  mild  attack  of  cholera  morbus,  in  that  the  abdom- 
inal pain  was  not  very  severe.  No  vomiting  occurred.  By  the 
use  of  chlorodyne  in  full  doses  he  was  able  to  remain  out  of  bed 
for  four  days,  but  at  the  end  of  that  time  was  seized  with  a  severe 
rigor  followed  by  moderate  fever  rising  to  104°.  He  then  devel- 
oped mild  typhoid  symptoms,  but,  ten  days  after  the  fever  ceased, 
suffered  from  a  severe  relapse.  It  was  found  that  just  thirteen 
days  prior  to  the  diarrhoea  he  had  eaten  raw  clams  contaminated 
by  sewage,  and  that  eight  other  persons  who  ate  of  the  same  lot  of 
clams  also  had  the  disease.  The  active  diarrhoea  in  this  case,  fol- 
lowed by  wretchedness  and  general  malaise,  was  naturally  supposed 
to  be  in  no  way  connected  with  a  definite  and  specific  infection. 

Still  another  case  of  this  kind  is  that  of  a  patient  admitted  to 
my  wards  with  a  history  that  up  to  January  Kith  he  had  been  in 
good  health,  but  on  that  day,  while  working  in  a  sugar-house,  and 
exposed  to  high  temperature,  he  had  taken  large  draughts  of  cold 
water,  which  speedily  produced  symptoms  of  cholera  morbus,  fol- 
lowed   by  headache  and  anorexia,  and  these  again    by  the  early 


56       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

symptoms  of  enteric  fever,  which  caused  him  to  come  under  my 
care  a  week  later  with,  as  additional  symptoms,  signs  of  conges- 
tion of  the  middle  lobe  of  the  right  lung.  Rose  spots  appeared 
on  the  ninth  day  of  his  illness. 

Pepper  and  Stengel1  have  reported  seven  cases  of  abrupt  onset 
in  typhoid  fever,  and  they  assert  that  Moore,  in  his  Text-book  of 
Eruptive  and  Continuous  Fevers,  published  in  1892,  is  the  only 
authority  who  calls  particular  attention  to  these  cases  in  which 
the  disease  begins  abruptly  and  with  vehemence,  characterized  by 
decided  rigors,  violent  headache,  and  rapid  rise  of  temperature. 
Moore  thinks  that  the  whole  course  of  the  disease  is  becoming 
more  typhus-like  than  formerly.  Pepper  and  Stengel's  seven 
cases  may  be  divided  into  two  classes  :  those  in  which  the  prelimi- 
nary symptoms  were  simply  gastro-intestinal  in  character,  vomit- 
ing, purgation,  and  high  fever  being  present,  and  others  in  which 
violent  headache  and  catarrh  of  the  throat,  nose,  and  bronchial 
tubes  was  marked. 

Symptoms  of  Onset  Connected  with  the  Nervous  System.  Of 
the  nervous  manifestations  of  typhoid  invasion  three  chief  types 
may  be  mentioned,  namely,  (a)  that  in  which  the  patient  suffers 
from  delusions  or  aberration  of  mind  and  wanders  from  home 
until  he  becomes  so  ill  as  to  fall  and  be  taken  to  a  hospital,  or, 
perhaps,  loses  his  life  through  exhaustion,  or  accident  due  to  his 
stupid  mental  state,  or  by  means  of  deliberate  suicide,  (b)  The 
second  class  is  that  in  which  acute  maniacal  symptoms  ensue, 
(c)  The  third  class  in  which  evidences  of  meningitis  are  marked ; 
so  marked  that  true  meningitis  is  supposed  to  be  present,  or  in  its 
place  meningitis  secondary  to  croupous  pneumonia.  In  many  of 
these  cases  there  is  little  doubt  that  the  pulmonary  lesions  of 
typhoid  infection  are  responsible  for  the  meningeal  signs,  while, 
on  the  other  hand,  it  is  possible  for  direct  infection  of  the  men- 
inges by  the  typhoid  organism  to  occur,  although  this  is  rare. 
(See  further  on.) 

Some  years  ago  myself  and  Patek  collected  the  following  cases 

1  Philadelphia  Medical  Journal,  vol.  i.  No.  2. 


VARIETIES  OF  ONSET.  57 

of  mental  disturbance  in  onset  which  we1  found  in  the  literature 
of  the  subject  : 

Murchison2  reports  the  case  of  a  German  who  was  much 
excited  over  the  Franco-Prussian  War.  After  about  four  days 
of  discomfort  and  malaise,  he  suddenly  passed  into  a  state  of 
acute  maniacal  delirium,  requiring  two  men  to  control  him. 
There  was  an  absolute  refusal  of  food,  a  temperature  of  102°, 
with  a  dry  tongue  and  rapid  pulse,  slight  diarrhoea,  and  no 
spots.  The  patient  was  subdued  by  large  doses  of  chloral,  and 
the  fever  ran  its  course.  The  same  author  also  states  that  in 
several  instances  he  has  known  acute  mania  to  develop  on  the  first 
day  of  an  enteric  fever,  and  that  under  these  circumstances  the 
case  is  very  apt  to  be  mistaken  for  insanity. 

AYilson3  asserts  that  delirium  may  be  an  early  symptom  of 
enteric  fever,  and  quotes  Riberalba,  who  reported  four  cases  which 
were  delirious  ou  admission  to  the  hospital.  Louis  saw  two  cases 
which  were  delirious  on  the  first  night  of  their  illness.  Bristowe 
has  also  reported  a  case  in  which  maniacal  delirium  existed  on  the 
second  day.  Mottet  mentions  an  instance  of  typhoid  fever  com- 
plicated with  mania  to  such  a  marked  extent  that  the  patient  was 
placed  in  an  asylum  before  the  true  nature  of  the  ailment  was 
discovered,  and  Henrot  and  Bucquoy  have  seen  the  disease  ushered 
in  with  the  delirium  of  grandeur.  Finally,  Daly4  records  an 
instance  in  which  aggressive  mania  came  on  on  the  fifth  day,  fol- 
lowing a  condition  of  stupor. 

From  a  careful  examination  of  a  large  amount  of  literature  I 
am  convinced  that  prodromal  insanity  in  enteric  fever  is  most 
rare  and,  when  it  occurs,  is  almost  always  fatal,  while  the  insanity 
which  is  in  the  nature  of  a  sequela  may  be  looked  upon  as  devoid 
of  immediate  or  remote  danger  to  mind  or  body. 

Iu  very  rare  instances  delirium  may  be  almost  the  first  symp- 
tom of  typhoid  fever.      Indeed,  it  may  actually  precede  the  devel- 

1  Bare  and  Patek,  Medical  News,  1892. 

2  Lancet,  1870,  vol.  ii.  p.  807. 

3  Philadelphia  Medical  Times,    1884-85,  vol.  xv.  p.  577-681. 

4  The  Medical  News,  1882,  vol.  xl.  p.  68. 


58       COMPLICATIONS  AND  SEQUEL JE  OF  TYPHOID  FEVER. 

opmeut  of  pyrexia ;  thus  in  seventeen  cases  which  have  -been 
collected  from  literature  by  Aschaffenbourg,1  seven  were  charac- 
terized by  the  development  of  delirium  before  the  fever,  and  the 
latest  period  at  which  it  was  observed  among  these  cases  of  early 
delirium  was  the  end  of  the  first  week.  As  a  rule,  the  delirium 
lasted  only  a  few  days,  but  the  mortality  was  high,  six  of  the 
seventeen  patients  dying.  Among  these  cases  the  delirium  occurred 
in  two  forms,  either  the  patients  were  exceedingly  restless  and 
violent,  finally  becoming  torpid,  or  there  was  a  condition  of  confu- 
sional  insanity,  in  which  the  patients  sang,  prayed,  danced,  or  were 
gay  or  sad. 

The  following  cases  met  with  by  Patek  and  myself  are  of 
interest :  Annie  M.,  aged  twenty-four  years,  was  admitted  to 
St.  Agnes'  Hospital,  March  18,  1891.  She  had  been  feeling 
badly  for  some  time,  but  until  four  days  previously  had  been  able 
to  do  her  work.  On  the  14th  she  had  a  severe  headache,  vomited 
a  little,  suffered  from  pain  in  the  stomach,  and  had  some  diarrhoea, 
these  symptoms  being  followed  on  the  subsequent  day  by  not  very 
profuse  epistaxis.  She  walked  a  considerable  distance  to  the  hos- 
pital, and  on  her  admission,  at  10  p.m.,  her  temperature  was  found 
to  be  105°.  The  resident  physician  found  that  her  tongue  was 
thickly  coated,  dry  and  brown.  On  the  next  day  when  seen  by 
us  in  the  wards  the  tongue  was  unusually  clean  even  for  that  of  a 
healthy  person.  The  patient  was  delirious  and  so  violent  that  it 
required  four  or  five  persons  to  keep  her  in  bed.  The  tempera- 
ture, after  an  unusually  prolonged  and  severe  struggle,  was  found 
to  be  106°. 

At  this  time  every  symptom  of  typhoid  fever  was  completely 
masked  by  the  insanity.  The  bowels  were  moved  and  the  passages 
were  of  normal  consistency  and  color.  The  urine  was  somewhat 
scanty  and  high  colored,  and  the  pulse  full  and  strong.  There 
were  no  rose  spots  or  other  enteric  symptoms.  At  the  end  of 
twenty-four  hours  the  patient,  still  being  in  a  condition  of  wild 
insanity  was  removed  to  a  cell,  the  impression  being  that  it  might  be 

1  Archives  de  Neurologie,  March,  1895. 


VARIETIES  OF  ONSET.  59 

a  case  of  hysterical  mania  with  hyperpyrexia.  Twenty-four  hours 
later  the  insanity  had  disappeared,  and  the  typhoid  symptoms  as- 
serted themselves  ;  the  delirium  became  more  quiet  and  muttering, 
and  she  was  taken  back  to  the  wards.  During  the  following  week 
she  was  constantly  delirious,  and  frequently  maniacal,  although 
there  were  short  momentary  intervals  of  sanity.  During  this  time 
a  large  number  of  rose  spots  appeared  on  the  abdomen  and  chest, 
the  tongue  became  heavily  and  typically  furred,  the  temperature 
followed  a  characteristic  course,  the  typhoid  odor  was  present,  and 
an  occasional  nose-bleed  helped  to  confirm  the  diagnosis  of  typhoid 
fever.  The  patient  rapidly  became  worse,  and  died  thirteen  days 
after  admission,  without  becoming  sane,  except  for  the  brief  inter- 
vals named. 

The  second  case  is  as  follows  : 

Mr.  A.,  a  resident  of  Milwaukee,  aged  thirty-four  years  ;  mar- 
ried ;  one  child.  A  sister  died  of  convulsions  of  unknown  nature 
but  a  short  time  before  the  onset  of  his  illness.  Family  history 
otherwise  negative.  At  the  age  of  seventeen  years  the  patient, 
according  to  the  statement  of  his  physician,  had  an  attack  of 
typhoid  fever,  attended  with  as  much,  if  not  more,  delirious 
excitement  than  this,  the  second  attack.  The  history  of  the  case 
begins  with  the  circumstance  that  Mr.  A.  was  nursing  his  wife, 
who  was  down  with  a  mild  attack  of  typhoid.  The  patient's  first 
complaint  was  of  headache  and  insomnia.  The  visiting  physician, 
seeing  him  on  the  following  day,  ordered  him  to  bed,  recognizing 
the  case  as  one  of  typhoid  fever,  rather  because  of  the  existence 
of  a  like  case  in  the  same  house  and  from  the  mere  complaint  of 
malaise,  than  from  any  symptoms  particularly  characteristic  of  the 
disease.  The  patient  obeyed  the  instructions  of  the  physician,  and 
went  to  bed,  still  complaining  of  insomnia.  Hardly  had  he  fallen 
into  a  mild  slumber  when,  not  more  than  an  hour  later,  he  sud- 
denly awoke,  delirious,  and  grew  steadily  more  so.  During  the 
following  night  he  became  maniacal,  rushed  to  the  room  of  the 
nurse  (she  had  been  procured  since  the  husband's  illness),  burst 
open  the  door,  threw  the  nurse  to  the  floor,  and  assaulted  her  in 
a  most  violent  manner,  kicking  and  striking  her,  and  accusing  her 


60       COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER. 

of  wishing  to  harm  his  wife  and  child.  The  nurse  finally  man- 
aged to  escape,  and  ran  for  the  physician,  who  lived  across  the 
street.  In  the  meantime  the  patient  jumped  through  a  window 
leading  to  a  small  balcony  over  the  front  portico,  and  leaped  to 
the  ground,  where  he  was  found  a  few  minutes  later  by  the  physi- 
cian. Strange  to  say,  the  man  suffered  little  injury,  being  slightly 
bruised  by  the  fall,  and  somewhat  cut  by  the  glass  ;  but  stranger 
still  was  the  fact  that  he  was  now  quite  rational,  telling  the  physi- 
cian all  that  had  transpired  and  what  he  had  done.  The  patient 
was  again  put  to  bed,  now  apparently  quite  comfortable.  The 
physician  left  him  to  see  the  wife  in  an  adjoining  room.  Hardly, 
however,  had  he  gone  when  Mr.  A.  suddenly  sprang  from  the 
bed,  rushed  into  the  kitchen,  where  he  seized  a  large  knife,  and 
then  rushed  back,  bent  upon  assaulting  the  physician.  He  was, 
however,  overpowered  and  again  forced  to  bed.  He  now  rested 
comfortably,  and  when  seen  the  following  day  was  doing  well. 
That  evening  a  condition  of  hyperpyrexia  suddenly  intervened, 
and  in  a  few  hours  the  patient  was  dead. 

The  following  case  is  of  interest  in  this  connection,  and  was 
seen  by  me  through  the  courtesy  of  Dr.  Higbee,  of  Philadelphia, 
who  called  me  in  consultation. 

An  unusually  large,  muscular  man,  about  thirty-five  years  of 
age,  after  two  or  three  days  of  wretchedness  and  malaise,  with 
slight  headache,  developed  fever  of  moderate  degree  on  the  fourth 
day,  and  that  evening  became  maniacally  delirious,  so  that  it 
required  four  or  five  of  his  fellow-workmen  to  hold  him  in  bed. 
On  these  workmen  becoming  exhausted  the  following  night  two 
male  nurses  were  put  in  charge  of  him,  but  he  fought  them  so 
vigorously  that  they  refused  to  take  care  of  the  patient  when  the 
morning  arrived,  as  they  stated  he  was  so  powerful  that  he  threw 
them  all  about  the  room. 

When  I  saw  him  after  two  nights  of  violent  delirium  of  this 
character,  he  was  perfectly  himself,  mentally,  and  described  his 
condition  and  his  sensations  to  me,  using  unusually  good  English 
for  a  man  in  his  walk  of  life,  and  evidently  having  an  intelligent 
idea  of  the  chief  symptoms  to  which  he  was  subject.     He  had  no 


VARIETIES  OF  ONSET.  61 

recollection  of  his  delirium,  but  he  had  been  told  by  his  wife  of 
the  struggles  that  they  had  had  with  him  on  the  previous  night. 

An  exceedingly  careful  examination  of  his  chest  revealed  at  the 
apex  of  the  right  lung,  anteriorly,  a  small  patch  where  there  was 
impaired  resonance  and  the  other  physical  signs  of  pulmonary  con- 
solidation, and  after  consultation,  Dr.  Higbee  and  I  agreed  that  it 
was  one  of  those  cases  of  pneumonia  in  which  there  was  a  re- 
markably small  pulmonary  lesion,  accompanied  by  severe  menin- 
geal and  cerebral  symptoms.  Something  about  the  case,  however, 
made  me  suspicious  of  a  typhoid  infection,  and  I  stated  to  Dr. 
Higbee  that  while  there  were  no  symptoms  of  typhoid  fever 
present  that  I  could  point  to,  I  was  suspicious  of  the  development 
of  this  disease.  That  evening  the  man  again  became  maniacally 
delirious  to  such  an  extent  that  his  family  recognized  that  it  was 
impossible  to  keep  him  at  home,  and  he  was  admitted  to  the 
hospital,  where  he  died  in  forty-eight  hours  from  exhaustion. 
The  autopsy  revealed  typical  typhoid  ulceration  of  the  bowel  and 
other  pathological  evidences  of  well-marked  typhoid  fever. 

This  case  illustrates  very  well  not  only  the  fact  that  pneumonia 
and  typhoid  infection  may  exist  side  by  side,  the  pulmonary  con- 
dition being,  perhaps,  directly  due  to  the  infection  of  the  bacillus 
of  Eberth,  but  also  that  cerebral  symptoms  of  great  severity  may 
usher  in  both  typhoid  fever  and  pneumonia. 

Osier  records  two  cases  of  curious  aberrant  mental  state  in  the 
stage  of  onset.  In  one,  a  young  girl  began  her  illness  by  doing 
odd  things  and  having  laughing  and  crying  spells  ;  the  other, 
also  a  young  wroman,  was  distinctly  "  off  her  head,"  so  that  she 
was  regarded  as  a  pure  mental  case. 

There  is  still  another  nervous  type  of  onset  which  is  exceed- 
ingly rare,  namely,  that  of  rapidly  developing  stupor  and  coma. 

Very  rarely  in  children  the  disease  is  ushered  iu  by  a  convul- 
sion, as  in  a  case  recorded  by  Osier,  and  in  the  case  of  convul- 
sions reported  by  Green,  and  detailed  in  an  earlier  part  of  this 
essay.  Convulsions  when  met  with  in  adults  are  usually  seen  in 
the  later  portions  of  the  disease,  and  depend  upon  embolism  or 
thrombosis  of  important  cerebral  vessels. 


62       COMPLICATIONS  AND  SEQUEL  jE  OF  TYPHOID  FEVER. 

The  Skin  in  the  Stage  of  Onset.  As  is  well  known,,  the 
characteristic  rash  of  typhoid  fever  does  not  make  its  appearance, 
as  a  rule,  until  the_S£xefi&-w-«inth  day,  and,  therefore,  it  cannot 
be  considered  a  symptom  of  onset  in  typhoid  fever.  Cases  do  occur, 
however,  in  which  in  this  stage  of  the  disease  aberrant  rashes 
develop.  Thus  the  writer  has  under  his  care  at  the  present  time 
a  man  of  twenty-two  years,  who  entered  the  hospital  on  the  third 
day  of  his  illness  so  covered  by  a  profuse  scarlatiniform  rash  that 
a  differential  diagnosis  as  to  its  true  character  was  impossible.  It 
persisted  for  three  days,  and  then  gradually  faded,  and  the  case 
ran  a  course  of  typical  typhoid  fever.  (See  the  chapters  on  the 
skin  in  the  well-developed  and  convalescent  stages.) 


CHAPTEE   III. 

THE  ABERRANT  SYMPTOMS,  STATES,  OR  COMPLICATIONS  OF 
THE  WELL-DEVELOPED  STAGE  OF  THE  DISEASE. 

Temperature  in  the  Developed  Disease.  We  may  pass  on, 
then,  to  a  consideration  of  excessive  symptoms  and  complications  of 
the  developed  disease,  and  the  febrile  process  naturally  first  attracts 
attention.  Before  we  attempt  to  study  the  unusual  febrile  condi- 
tions seen  in  patients  who  have  passed  the  stage  of  onset  and  are 
in  the  well-developed  period  of  the  malady,  it  may  be  well  to  con- 
sider briefly  what  the  normal  or  usual  febrile  movement  really  is. 
This  Striimpel  well  describes  when  he  says  that  the  second  division 
of  the  curve  represents  the  so-called  fastigiuni,  and  corresponds  to 
the  height  of  the  disease.  "  During  this  time  the  fever  presents 
in  most  of  the  severer  cases  the  general  character  oifebris  eontinua 
— that  is,  the  spontaneous  remissions  of  the  fever  seldom  exceed 
2°.  Almost  always  the  lower  temperatures  come  in  the  morning 
hours  and  the  higher  in  the  evening.  In  cases  of  average  severity 
the  morning  remissions  touch  102°  to  103°,  and  the  evening 
exacerbations  104°  to  105°.  Temperatures  which  reach  or  exceed 
106°  are  seen  only  in  very  severe  cases.  Considerable  morning 
remissions  are  always  a  favorable  symptom,  while  morning  tem- 
peratures of  104°  or  higher  generally  show  the  case  to  be  severe. 
The  duration  of  the  fastigium  varies  with  the  severity  and  obsti- 
nacy of  the  case.  It  may  last  only  a  few  days  or  one  and  a  half 
to  two  weeks ;  in  violent  cases  still  longer." 

Ampugnani1  has  proved  that  the  natural  maximum  occurs 
between  3  and  6  p.m.,  and  the  natural   minimum  between  5  and 

8  A.M. 

At  the  end  of  the  fastigium  the  temperature  gradually  falls 

1  London  Medical  Record,  January,  1S89. 


64       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

by  lysis  until  it  reaches  the  normal,  or  perhaps  more  frequently 
there  is  before  the  lysis  another  period  which  has  been  called  by 
Wuuderlich  the  "  ambiguous  period,"  in  which  the  morning  tem- 
peratures are  each  day  almost  normal  and  the  evening  tempera- 
tures only  slightly  lower  each  day.  In  other  cases  the  evening 
temperature  for  some  days  remains  as  high  as  before.  Murchison 
called  this  period  "  the  stage  of  changing  fortunes,"  and  Striimpel 
has  called  it  "  the  period  of  steep  curves,"  and  has  also  stated  that 
the  longer  a  case  lasts  the  more  marked  becomes  the  irregularity 
of  the  fever  at  this  time. 

The  case  recorded  in  this  chart  was  one  of  very  great  interest, 
because  as  the  fever  of  the  early  stage  of  the  disease  was  not 
marked,  and  the  abdominal  symptoms  were  prominent,  the  ques- 
tion arose  as  to  whether  the  patient,  who  was  five  months  pregnant, 
was  suffering  from  appendicitis,  uraemia,  sepsis  from  pelvic  disease, 
septic  endocarditis,  or  typhoid  fever.  There  was  scantiness  of  the 
urine,  half  the  normal  amount  of  urea,  albuminuria,  and  marked 
signs  of  general  toxeemia.  There  was  also  great  tenderness  of 
the  belly,  particularly  over  the  appendix,  and  considerable  pain 
in  this  region,  even  when  the  patient  was  lying  still.  In  addition 
there  was  also  great  difficulty  in  urination  and  obstinate  constipa- 
tion, and  the  pregnant  uterus  so  filled  the  lower  segment  of  the 
belly  and  displaced  the  bowels  that  diagnosis  was  unusually  diffi- 
cult. Auscultation  over  the  prsecordium  revealed  a  distinct  en- 
docardial murmur,  probably  due  to  the  anaemia  of  pregnancy. 
Had  these  steep  curves  been  met  when  the  patient  was  first  seen 
I  think  the  case  would  have  been  considered  one  requiring  opera- 
tion, because  they  would  have  led  me  and  the  surgical  consultant 
to  believe  that  the  symptoms  were  septic.  The  development  of 
a  profuse  rose  rash  and  the  Widal  reaction  cleared  the  diagnosis 
some  days  before  the  period  of  steep  curves  began. 

Having  set  up  a  normal  standard  for  the  course  of  typhoid  fever, 
we  find  that  variations  from  this  standard  occur  under  circum- 
stances, many  of  which  are  indicative  of  some  condition  well  worthy 
of  the  physician's  attention,  while,  on  the  other  hand,  some  aber- 
rant types  are  without  significance  so  far  as  our  present  knowledge 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE. 


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QQ       COMPLICATIONS  AND  SEQUEL  JE  OF  TYPHOID  FEVER. 

goes.  The  temperature  of  typhoid  fever  is,  as  is  well  known, 
rarely  as  high  as  in  many  other  of  the  grave  infectious  maladies, 
yet  at  times  it  may  become  in  itself  dangerous  by  reason  of  its 
height.  Sometimes,  though  rarely,  as  in  the  days  of  onset,  we  meet 
during  the  fastigium,  without  the  presence  of  an  additional  exciting 
cause  over  and  above  the  ordinary  typhoid  infection,  with  cases  in 
which  there  is  developed  a  distinct  hyperpyrexia  amounting  to 
105°,  or  even,  very  rarely,  to  110°. 

Such  high  temperatures  are  sometimes  seen  for  long  periods  of 
the  attack  as  the  result  of  nervous  excitement,  or  of  unusual  sus- 
ceptibility to  the  infection  in  the  sense  that  the  heat  mechanism  is 
easily  disturbed  by  the  disease.  These  cases,  as  a  rule,  however, 
do  not  persist  in  hyperpyrexia,  but  soon  fall  to  the  usual  level. 
When  the  fever  is  persistently  high  there  can  be  no  doubt  that,  as 
a  rule,  the  attack  is  one  of  a  severe  character.  Conversely,  a  low 
range  of  fever  is  indicative  of  a  mild  attack,  although  by  no  means 
proof  of  it,  for  moderate  fever  is  sometimes  seen  in  cases  charac- 
terized by  very  severe  infection.  Rarely  the  disease,  pursuing  a 
fatal  course,  is  accompanied  by  progressively  rising  fever  until 
toward  the  end  of  the  second  or  third  week  it  may  reach  107°  or 
even  110°,  as  has  been  recorded  by  Wunderlich. 

When  a  severe  and  prolonged  attack  of  typhoid  fever  is  present 
the  period  of  "  steep  curves "  may  be  postponed  from  the  end 
of  the  third  or  beginning  of  the  fourth  week,  or  even  to  the  fifth 
or  sixth  week,  and  in  these  cases  there  is  usually  wide-spread 
ulceration  of  the  small  and  large  intestine.  Additional  evidence 
of  this  condition  is  adduced  by  the  fact  that  the  abdomen  is  still 
tender  on  pressure,  and  the  so-called  meteorism  or  active  peris- 
taltic movement  is  persistent.  Care  must  be  taken  in  these  cases 
that  other  causes  than  uncomplicated  typhoid  fever  are  not  actively 
engaged  in  the  continuance  of  the  fever,  either  in  the  form  of  other 
infections  or  as  secondary  infections  by  the  bacillus  of  Eberth  of 
such  parts,  for  example,  as  the  gall-bladder,  the  kidney,  or  the  bones. 
Or,  again,  the  fever  may  be  continuous  as  the  result  of  a  tubercu- 
lous infection  superimposed  on  the  typhoid  trouble  or  antedating 
that  disease  in  time  of  entrance  into  the  body,  but  only  active 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  67 

when  vital  resistance  is  decreased  by  the  exhaustion  of  typhoid 
fever.     (See  further  on.) 

Among  the  particularly  noteworthy  causes  of  sudden  rises  of 
fever  during  the  fastigium,  or  in  the  period  of  ambiguity,  or  during 
lysis,  we  find  the  development  of  some  acute  complication,  such 
as  pneumonia,  catarrhal  or  croupous,  abscess  in  some  part  of  the 
body,  and  what  has  been  called  "  intercurrent  relapse."  The 
pneumonia  at  this  period  is  often  of  the  croupous  type  (8  per 
cent.),  and  pleurisy  may  also  develop  (8  per  cent.),  but  their  onset 
may  not  noticeably  disturb  the  temperature  curves,  so  that  while 
the  presence  of  a  rise  may  be  indicative  of  another  source  of  diffi- 
culty, its  absence  does  not  indicate  that  no  secondary  pulmonary 
trouble  has  arisen ;  more  rarely  still  catarrhal  pneumonia  elevates 
the  temperature,  and  its  very  insidious  onset  makes  it  readily  over- 
looked, while  the  development  of  hypostatic  congestion  may  make 
no  change  at  all.  The  temperature  under  some  circumstances  rises 
quite  suddenly,  and,  after  maintaining  a  generally  higher  course 
for  a  few  days,  begins  to  drop  back  to  its  former  level,  or  at  once 
the  whole  temperature  course  passes  into  the  stage  of  lysis.  So, 
too,  an  otic  abscess  may  produce  such  results,  and,  finally,  should 
an  intercurrent  relapse  ensue,  the  fever,  gaining  new  force,  may 
mount  to  a  point  as  high  or  higher  than  any  previously  reached, 
and  last  from  ten  days  to  two  weeks  or  more,  falling  again  as  a 
tendency  to  lysis  is  developed.  The  presence  of  a  mild  primary 
attack  followed  by  a  relapse  after  several  days  of  no  fever,  and 
finally  complicated  by  phlebitis,  with  fever  secondary  to  it,  and 
then  a  second  relapse,  is  shown  in  this  chart. 

It  is  important  that  a  secondary  exacerbation  of  the  fever  be 
not  regarded  as  indicative  of  true  relapse  unless  it  persists,  un- 
less it  is  followed  by  a  renewal  of  many  or  all  of  the  earlier 
symptoms  of  the  disease,  and  unless  the  eruption  and  enlarge- 
ment of  the  spleen  a  second  time  indicate  true  secondary  infec- 
tion. Not  only  is  the  physician  to  avoid  a  diagnosis  of  relapse 
until  it  is  proved  to  be  present,  for  the  sake  of  accuracy,  but 
in  addition  he  must  avoid  it,  because  it  is  an  easy  way  to  ex- 
plain temperature  irregularities,  which  should  cause  him  to  care- 


68        COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 


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70       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

fully  search  for  complicating  affections.  To  sum  up  this  matter 
with  brevity,  it  should  be  the  rule  to  consider  any  sudden  and 
considerable  rise  of  fever  above  the  ordinary  lines  previously  fol- 
lowed, an  indication  of  some  other  factor  than  the  ordinary  typhoid 
infection.  These  various  complicating  states  which  are  productive 
of  febrile  movement  will  be  discussed  later  on  when  studving  the 
lesions  found  in  various  organs. 

Of  the  cases  in  which  the  temperature  is  of  low  degree  and 
mild,  much  may  be  said.  In  the  first  place,  in  very  rare  instances 
cases  occur  in  which  there  is  not  only  no  fever,  but  actually  a  con- 
dition of  subnormal  temperature  from  the  beginning  to  the  end  of 
the  attack.  Thus  in  several  cases  under  the  writer's  care,  some 
years  since,  there  was  a  characteristic  temperature  curve  in  form 
but  not  in  degree,  the  morning  temperature  being  distinctly  sub- 
normal and  the  evening  temperature  normal,  and  in  which  the 
return  to  health  consisted  in  a  "  lysis,"  so  to  speak,  in  which  the 
temperature  gradually  rose  to  normal  instead  of  falling.  Again, 
almost  equally  rarely  there  is  no  temperature  movement  what- 
ever in  the  sense  that  the  temperature  is  either  above  or  below 
normal. 

Cases  of  this  type  have  been  recognized  for  many  years  by  close 
students  of  the  disease,  but  are  not  commonly  recognized  by  the 
general  practitioner,  who  is  taught  in  the  medical  schools  to  regard 
fever  as  a  necessary  symptom  of  this  malady.  Many  years  ago  the 
elder  Miescher  recognized  these  cases,  and  Liebermeister  recorded, 
in  1869,  139  cases  of  "afebrile  abdominal  catarrh,"  which  he 
thinks  were  in  large  part  due  to  typhoid  infection,  and,  in  1870, 
111  cases  of  the  same  character.  Many  of  these  cases  showed 
evident  enlargement  of  the  spleen,  and  in  some  instances  a  roseola. 
Strabe1  has  described  fourteen  cases  in  which  no  fever  was  pres- 
ent, although  at  times  the  temperature  was  subnormal,  and  in 
which,  nevertheless,  the  other  characteristic  symptoms  of  enteric 
fever  were  present  to  so  marked  a  degree  that  they  could  not  be 
mistaken  for  any  other  disease.     The  mortality  in  these  cases  was 

1  Berliner  klin.  Wochenschrift,  1871,  No.  30. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  71 

no  less  than  14.1  percent.  So,  too,  Fraentzel1  has  recorded  forty- 
one  cases  treated  in  a  field-hospital  during  the  Franco-Prussian 
war,  in  three  of  which  the  fever  did  not  exceed  99.1°,  and  in  the 
rest  did  not  arise  above  102.2°,  and  yet  in  which  the  mortality 
was  89  per  cent,  for  the  forty-one  patients.  Guiteras2  records  a 
case  in  which  he  diagnosed  the  condition  as  intestinal  obstruction, 
in  which  the  patient  died  of  peritonitis,  and  at  the  autopsy  the 
lesions  of  typhoid  fever  was  found,  although  no  fever  had  been 
present.  Tallin3  records  a  case  of  death  due  to  perforation  in  an 
afebrile  typhoid  fever  patient,  and  another  of  intestinal  hemor- 
rhage in  a  similar  case,  and  the  writer  has  seen  several  afebrile 
cases  in  one  epidemic.  In  still  another  epidemic  another  instance 
was  met  with,  which  has  been  recorded  in  the  Memphis  Lancet 
for  July,  1898.     (See  further  on.) 

In  La  Province  Jledicale,  November  26,  1897,  Weill  and  Piery 
report  a  case  of  apyretic  typhoid  fever,  which  they  considered  in 
other  ways  entirely  typical. 

Two  cases  of  apyretic  typhoid  fever  have  also  been  recorded  by 
\Yendland.4  These  cases  were  confirmed  by  autopsy,  and  illus- 
trate, at  least  to  the  satisfaction  of  Wendland,  that  temperature 
is  not  a  true  index  of  the  severity  of  the  disease. 

Similar  cases  have  been  recorded  by  Fisk,  of  Denver,  and  they 
are  represented  by  the  following  case  : 

The  patient  was  a  male  with  a  negative  history,  except  that  he 
had  true  typhus  fever  at  ten  years.  On  admission  he  had  a  tem- 
perature of  98.4°;  pulse,  84 ;  respirations,  26  ;  the  tongue  was 
coated,  showing  distinct  red  tip  and  edge  ;  he  had  an  apathetic 
appearance,  and  complained  of  headache  ;  the  pupils  were  dilated, 
there  were  tenderness  and  gurgling  in  the  right  iliac  fossa.  He 
still  had  constipation,  but  when  by  medication  the  bowels  were 
acted    upon,  the  fecal  matter  was  of  pea-soup  color  and   liquid. 

1  Zeitschrift  fur  klinische  Medizin.  1881,  p.  226. 

2  Transactions  of  the  Association  of  American  Physicians,  1887. 

3  Archives  Generale  cle  Med.,   November,  1873;    see  also  Liebermeistcr  and 
Hagenbach  A  us  der  med.  klin.  zu  Basel,  1869,  \>.  9. 

4  Deutsche  Medizinal  Zeitung,  August  •_'!>.  1SU3. 


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WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  73 

There  was  an  eruption  of  "rose  spots;"  the  spleen  was  normal. 
Upon  the  patient's  abdomen  and  back  were  found  numerous  pale- 
blue  spots — tache  bleudtre.  ('lose  inspection  also  showed  evi- 
dences of  pediculosis,  several  ova  being  attached  to  hairs. 

Later  it  was  noted  that  the  spleen  was  slightly  enlarged,  also 
that  the  palms  showed  the  characteristic  yellow  tint ;  constipation 
still  existed,  but  the  pulse  was  not  so  rapid  as  on  admission. 

The  urine  was  yellow;  specific  gravity,  10*20;  acid,  no  sugar, 
no  albumin. 

Later  the  headache  nearly  disappeared,  but  stupor  still  con- 
tinued.    The  diagnosis  was  afebrile  typhoid. 

The  accompanying  temperature-chart  is  an  interesting  confir- 
mation of  this  history  : 

Dreschfeld  also  mentions  this  form  of  apyrexial  typhoid  fever. 

Under  the  name  of  typhus  levissvmus,  Griesinger  first  described 
forms  of  enteric  fever  in  which  the  febrile  movement  was  not  only 
very  mild,  but  in  which  the  symptoms  in  general  were  of  the  most 
moderate  form,  the  entire  course  of  the  disease  lasting  only  eight 
to  fourteen  days. 

In  that  condition  known  as  "  abortive  typhoid  fever,"  the 
severe  onset  and  high  fever  may  so  soon  be  followed  by  modera- 
tions and  signs  of  convalescence,  with  a  falling  temperature,  that 
the  course  of  the  temperature  may  be  most  aberrant  and  the  chart 
misleading. 

Here,  again,  however,  as  in  all  the  variations  of  temperature 
just  described,  the  physician  must  not  be  readily  led  into  a  diag- 
nosis of  an  aberrant  form  of  typhoid  fever  by  the  knowledge 
that  such  aberrant  forms  occur,  for  these  forms  are  so  infrequent 
as  to  be  curiosities,  and  are  so  rare  that  the  probabilities  in  an 
obscure  case  are  against  their  presence.  Only  the  clear  and 
undoubted  development  of  a  sufficient  number  of  pathognomonic 
symptoms  coupled,  if  possible,  with  a  positive  reaction  with  the 
Widal  test  and  with  a  history  of  recent  possible  typhoid  infection 
should  cause  the  physician  to  reach  a  diagnosis  of  these  types  of 
enteric  fever. 

In  aged  persons  enteric  fever  is  usually  mild  in  its  temperature 


74       COMPLICATIONS  AND  SEQUEL M  OF  TYPHOID  FEVER. 

curves,  and  the  characteristic  febrile  movement  is  so  irregular  and 
distorted  as  to  be  devoid  of  much  diagnostic  value. 

In  some  cases  the  fever  is  peculiar  in  that  it  fails  to  follow  the 
so-called  normal  rise  in  the  evening  and  slightly  lower  degree  in  the 
morning,  and  is  supplanted  by  a  reverse  type  in  which  the  morn- 
ing temperature  is  highest.  Such  an  occurrence  took  place  in  the 
case  reported  to  me  by  Krusen,  which  is  quoted  in  Chapter  I. 

Fig.  12. 


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Abortive  typhoid  fever  ending  by  the  seventh  day,  and  by  crisis  instead  of  lysis. 

In  this  connection,  too,  it  must  be  remembered  that  in  some 
cases  (not  many),  during  the  course  of  the  second  week,  the  fever 
develops  a  type  closely  resembling  that  seen  in  remittent  malarial 
fever.  According  to  many  writers  on  diseases  of  children,  this 
form  of  the  fever  is  by  no  means  rare  in  this  class  of  patients. 
Again,  as  this  week  or  the  third  week  ends,  the  febrile  movement 
may  even  be  distinctly  like  that  of  a  malarial  intermittent  with- 
out there  being  any  malarial  infection  of  the  patient  whatever. 
Striimpel  speaks  of  such  cases  in  which  distinct  remittance 
occurred,  and  of  others  in  which  the  fever  was  completely  inter- 
mittent, the  afternoon  temperature  for  two  or  three  weeks  being  as 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  75 

high  has  104°,  yet  followed  by  morning  temperatures  at  the  norma] 

point,  and  Pepper  has  expressed  the  belief  that  these  great  varia- 
tions are  in  part  the  result  of  marked  sepsis  and  intestinal  ulcera- 
tion. Tims  he  has  seen  as  much  as  7  degrees  variation  occur  for 
several  days  in  succession.  Such  variations  should  never  be  con- 
sidered curiosities  in  typhoid  fever,  but  should  stimulate  the  med- 
ical attendant  to  increased  endeavor  to  discover  a  septic  source  other 
than  the  intestinal  lesions  as,  for  example,  a  septic  kidney.  They 
may  occur,  however,  in  cases  without  complicating  diseases  or 
lesions,  as  is  shown  in  Fig.  12. 

In  this  man's  case  the  blood  was  examined  repeatedly  for  the 
malarial  organism,  with  negative  results,  and  there  was  no  history 
of  exposure  to  it.  Cases  of  this  type  are  also  recorded  by  Her- 
ringham,  who  discusses  these  temperature  variations  in  St.  Barthol- 
crmew's  Hospital  Reports  for  1896.  In  one  of  these  a  woman  of 
thirty-three  years  had  severe  rigors  followed  by  high  fever  on  the 
evening  of  the  twenty-third  and  the  morning  and  evening  of  the 
twenty-fourth  day  of  the  disease.  These  rigors  were  followed  by 
a  fall  of  fever,  which  amounted  to  a  crisis,  and  speedy  convales- 
cence ensued.  In  still  another  case  chills  and  fever  occurred  on 
the  thirty-first,  thirty-fifth,  and  thirty-sixth  day  of  the  illness, 
followed  by  two  attacks  on  the  thirty-eighth  day.  These  were  in 
turn  followed  by  crisis  and  recovery.  In  the  other  cases  reported 
by  Herringham  a  rigor  occurred  in  one  during  the  acme  and  later 
during  lysis  ;  in  another  at  the  onset  of  lysis ;  in  another  in  lysis  : 
in  another  a  number  of  rigors  occurred  in  acme  and  severe  rigors 
in  lysis,  probably  due  to  thrombosis.  Osier  has  also  reported  a 
case  of  this  type.1  Church2  has  recorded  a  case  in  which  a  girl 
had  twenty-two  rigors  in  a  primary  attack  in  fourteen  days, 
twenty-five  in  fifteen  days  in  a  first  relapse,  and  six  in  eleven 
days  in  a  second  relapse. 

It  is  well  to  recall  the  fact  insisted  upon  by  no  less  an  authority 
than  Janeway,3  that  the  use  of  the  coal-tar  products  in  the  course 

1  Johns  Hopkins  Hospital  Reports,  L895,  No.  5. 

2  St.  Bartholomew's  Hospital  Reports,  L896. 

5  Transactions  of  the  Association  of  American  Physicians,  1894. 


76        COMPLICATIONS  AND  SEQUEL JE  OF  TYPHOID  FEVER. 


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« 

78       COMPLICATIONS  AND  SEQUEL  JE  OF  TYPHOID  FEVER. 

of  enteric  fever  may  have  a  chill-producing  effect.  It  is  well 
known  that  the  external  use  of  guaiacol  will  produce  severe  rigors. 

In  other  cases  presenting  such  rigors  there  is  present  a  true 
double  infection  of  typhoid  and  malarial  fever.      (See  further  on.) 

There  are  a  number  of  conditions  which  result  in  producing  a 
marked  and  sudden  fall  of  temperature  during  the  periods  of  the 
fastigium  and  defervescence  aside  from  the  sudden  drop,  rarely 
seen,  in  which  the  fever  ends  by  crisis  instead  of  lysis,  the  patient 
passing  into  convalescence  at  once.  The  most  important  of  these 
causes,  both  because  of  their  degree  and  because  of  what  they  indi- 
cate, are  hemorrhage  from  the  bowel,  or,  if  it  be  profuse,  that  from 
any  other  part  of  the  body,  perforation  of  the  bowel  and  the  rigor 
preceding  a  complicating  infection  such  as  pneumonia,  the  begin- 
ning of  a  relapse  or  the  effect  of  powerful  antipyretic  drugs. 
Often  great  falls  in  temperature  take  place  when  the  typhoid 
infection  is  associated  with  malarial  infection,  as  already  inti- 
mated.    (See  further  on.) 

In  the  case  of  a  complicating  disease  a  few  hours'  delay  in 
recognizing  its  presence  may  not  make  much  difference  to  the 
physician  or  patient ;  but,  on  the  other  hand,  the  early  recognition 
of  hemorrhage  or  perforation  may  save  the  patient's  life.  The 
symptoms  of  perforation,  associated  with  the  fall  of  fever,  are 
prominent  and  will  be  considered  under  the  head  of  gastrointes- 
tinal accidents,  but  in  the  case  of  intestinal  hemorrhage  the  fall 
may  occur  some  time,  it  may  be  several  hours,  before  the  appear- 
ance of  a  bloody  stool  enforces  the  belief  upon  the  nurse  that  hem- 
orrhage is  present.  For  this  reason  an  unexplained  marked  fall 
of  temperature  should  always  be  regarded  with  suspicion,  and  the 
appearance  of  the  next  stool  watched  with  interest.  The  pulse 
should  be  carefully  studied  for  signs  of  loss  of  blood,  and  the 
facial  expression  and  color  of  the  tongue  closely  watched.  If  the 
patient  is  conscious  and  capable  of  giving  expression  to  his  sensa- 
tions he  may  complain  of  a  sensation  of  faintness  or  of  sinking, 
or  if  the  hemorrhage  is  very  profuse  the  patient  may  pass  rapidly 
into  a  state  of  collapse  or  shock,  owing  to  the  extravasation  of 
blood  into  the  small  and  large  bowel,  dying  almost  simultaneously 


WELL-DEVELOPED  STAGE  OF  THE  DLSEASE.  79 

with  the  gush  of  blood  from  the  rectum.  Thus  I  have  seen  a  case 
apparently  passing  safely  through  a  moderately  severe  attack  of 
enteric  fever  suddenly  develop  the  symptoms  named,  present  all 
signs  of  marked  exsanguination,  and  then  pass  into  the  bed  an 
enormous  volume  of  half-clotted  blood,  which  extended  from 
the  anus  to  the  heels,  at  the  same  moment  developing  gasping 
respiration,  profound  syncope,  and  seeming  to  be  in  articulo  mortis. 
So,  too,  I  have  seen  actively  employed  hypodermoclysis  result  in 
the  recovery  of  patients  so  greatly  exsanguinated  that  death 
seemed  inevitable. 

Sometimes,  however,  even  profuse  intestinal  hemorrhage  recur- 
ring again  and  again,  fails  to  cause  a  very  great  fall  in  the  tem- 
perature, or  does  not  keep  it  low  but  for  a  short  time. 

Sometimes  well-developed  signs  of  collapse  appear  in  the  course 
of  typhoid  fever  without  indicating  any  serious  accident  in  the 
course  of  the  disease  which  could  produce  these  symptoms.  In 
this  state  the  patient  develops  a  rapid  pulse,  shallow  respirations, 
pallor  and  lividity,  accompanied  it  may  be  by  a  rigor.  There  is 
usually  a  marked  fall  of  temperature.  Herringham1  asserts  that 
these  symptoms  have  no  effect  on  the  prognosis,  and  that  treat- 
ment is  practically  unavailing.  On  the  other  hand,  they  may 
mean  that  the  patient  is  in  grave  danger,  as  has  been  pointed  out 
by  Landouzy  and  Siredey.2  (See  circulatory  changes  in  the  well- 
developed  and  convalescing  stages  of  the  disease.) 

How  far  constant  fever  occurring  day  after  day  and  associated 
with  manifestations  of  general  loss  of  strength  and  debility  can 
be  relied  upon  in  the  diagnosis  of  typhoid  fever  is  hard  to  deter- 
mine. Certain  it  is  that  if  a  physician  makes  a  diagnosis  of 
enteric  fever  upon  these  symptoms  alone,  without  bearing  in  mind 
the  fact  that  similar  conditions  are  equally  well  developed  under 
other  forms  of  infection,  he  will  find  himself  in  error  in  not  a  few 
instances.  Chief  among  these  may  be  mentioned  tuberculosis  of 
the  lungs  or  peritoneum,  that  form  of  influenza  in  which  the  chief 

1  St.  Bartholomew's  Hospital  Reports,  1SH<>. 

2  Revue  de  Medicine,  1887,  p.  804. 


80       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

symptoms  are  abdominal,  cases  of  ulcerative  endocarditis,  septi- 
caemia and  pyaemia,  and  those  of  cholecystitis  with  ulceration,  as 
from  impacted  gallstones.  It  must  not  be  forgotten,  too,  that  syph- 
ilitic fever  may  in  very  susceptible  persons  resemble  typhoid  infec- 
tion. The  febrile  movement,  rose  rash,  if  it  be  scanty,  malaise, 
and  signs  of  general  infection  may  readily  mislead  the  physician. 

Again,  in  the  more  advanced  stage  (tertiary)  of  syphilis  pro- 
longed, low  septic  fever  may  be  present. 

Finally,  let  it  not  be  forgotten  that  trichiniasis1  may  resemble 
typhoid  fever,  for  in  it  we  have  fever,  pains  in  the  limbs  and  back, 
headache,  stupor,  and  nausea,  with  pain  in  the  belly  and  diarrhoea. 

Points  in  differential  diagnosis  in  this  condition  are  the  pres- 
ence of  leucocytosis  (particularly  in  eosinophils),  and  its  absence 
in  typhoid  fever,  and  puffiness  of  the  bridge  of  the  nose. 

Not  only  may  the  fever  of  these  states  be  moderate  and  pro- 
longed and  the  evidences  of  asthenia  marked,  but  enlargement  of 
the  spleen,  diarrhoea,  and  tympanites  may  be  present.  The  difficul- 
ties in  differential  diagnosis  in  cases  of  suspected  gall-bladder  dis- 
ease are  increased  by  the  fact  that  such  disease  often  has  its  origin 
in  an  old  infection  of  the  gall-bladder  due  to  an  attack  of  typhoid 
fever  months  or  years  before,  the  bacillus  of  Eberth  being  present 
in  this  viscus  during  the  entire  interval,  or  in  other  cases  it  invades 
the  gall-bladder  at  the  onset  of  the  infection  of  the  entire  body, 
and  so  emphasizes  the  hepatic  symptoms.  Further  than  this, 
cases  which  have  previously  had  enteric  fever  may  also  give  the 
Widal  test,  although  the  immediate  cause  of  the  attack  may  be 
localized  in  the  manner  named.  These  forms  of  infection  will  be 
considered  later  on. 

Reference  has  already  been  made  to  the  possibility  of  the  febrile 
movement  resembling  that  of  malarial  fever.  In  some  cases  this 
infection  is  truly  present,  but  in  others  the  temperature-chart  is 
that  of  an  irregular  typhoid  fever. 

These  facts  bring  us  face  to  face  with  a  discussion  of  a  subject 

1  As  the  most  recent  paper  on  this  subject,  see  Osier,  American  Journal  of  the 
Medical  Sciences,  March,  1899. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  81 

about  which  great  diversity  of  opinion  exists,  and  has  existed  for 
years,  namely,  the  question  of  that  condition  which  has  been 
called  "  typho-malarial  fever."  At  the  present  time  it  may  be 
asserted  as  a  fact  that  a  separate  disease  entity  of  this  character 
does  not  exist,  and  this  is  done  on  the  basis  that  recent  discoveries 
in  the  natural  history  of  these  diseases,  particularly  the  recognition 
of  the  malarial  germ  on  the  one  hand  and  the  use  of  the  Widal 
test  on  the  other  has  enabled  us  to  make  an  absolute  diagnosis  in 
cases  in  which  so  positive  a  statement  has  heretofore  been  im- 
possible. 

There  is  no  doubt  whatever  that  pure  typhoid  infection  may 
result  in  the  production  of  a  fever  which  closely  follows  the 
remittent  and  intermittent  malarial  types,  and  which  is  often 
associated  with  so  much  gastric  disturbance  and  vomiting  and  so 
lacking  in  the  more  prominent  typhoid  symptoms  usually  seen 
that  the  picture  of  remittent  malarial  fever  is  clear,  while  the  true 
picture  of  typhoid  fever  is  clouded.  (See  also  chapter  on  diseases 
which  ape  typhoid  fever.)  Again,  there  can  be  no  doubt  that 
cases  of  true  malarial  infection  occur  in  which  the  symptoms  so 
closely  resemble  those  of  typhoid  fever  that  a  purely  clinical  diag- 
nosis is  almost  impossible,  particularly  if  an  epidemic  of  typhoid 
fever  is  in  full  swing  at  the  time.  Finally,  there  can  also  be  no 
doubt  that  it  is  possible  for  the  patient  to  have  a  double  infection 
with  the  bacillus  of  Eberth  and  the  plasmodium  of  Laveran,  in 
which  case,  however,  the  malarial  manifestations  are  usually 
dwarfed  by  the  typhoid  poison,  and  only  are  marked  at  the  onset 
of  the  enteric  fever  and  at  its  termination.  To  this  mixed  infection 
the  term  typho-malarial  fever  may  be  correctly  applied  to  indicate 
not  a  separate  disease,  but  a  double  infection.  Etymologically, 
this  term  might  also  be  used  to  define  a  condition  of  malarial 
fever  in  which,  because  of  profound  debility,  the  patient  was  in  a 
typhoid  state — that  is,  in  a  condition  of  which  typhoid  fever  is  a 
type.  Practically,  however,  it  should  be  discarded  or  limited  in 
its  use  to  the  double  infection  just  described. 

Johnston  has  well  said,  "As  at  the  present  employed  the 
term  typho-malarial  fever  has  no  determined   meaning,   leads  to 

6 


82       COMPLICATIONS  AND  SEQUEL  JE  OF  TYPHOID  FEVER. 

confusion  and  misunderstanding,   is  a  cover    for  uncertainty  and, 
ignorance,  and  should  be  discouraged  and  abandoned." 

As  already  shown,  there  can  be  no  doubt  that  mild  grades  of 
typhoid  infection  take  place  in  which  the  only  symptom  of  this 
disease  is  fever  which  runs  a  moderate  course,  and  is  accompanied 
by  a  certain  degree  of  general  debility.  Often  they  begin  rather 
abruptly,  with  a  slight  chill,  or  gradually  the  patient  feels  less  and 
less  well  till  he  takes  to  his  bed.  These  cases  are  characterized 
by  well-marked  remissions,  it  may  be,  and  suffer  from  somewhat 
indefinite  symptoms  difficult  of  classification.  They  do  not  respond 
to  quinine,  nor  do  they  show  any  typhoid  symptoms  other  than 
those  named,  and  the  diagnosis  arrived  at  will  depend  largely  upon 
whether  the  physician  is  practising  in  the  North  or  the  South,  is 
treating  many  cases  of  enteric  fever  or  many  of  remittent  fever, 
unless  he  is  skilful  with  his  microscope,  in  which  case  the  Widal 
reaction  for  typhoid  fever  in  a  majority  of  cases  will  at  some  time 
settle  the  diagnosis  for  him,  or  an  autopsy  will  show  typhoid 
lesions. 

Or,  on  the  other  hand,  he  may  find  the  malarial  organism  in 
the  blood,  which  will  prove  that  this  infection  is  present,  although 
it  will  not  exclude  typhoid  fever,  just  as  the  Widal  test  will  not 
exclude  malarial  infection. 

Atkinson  has  well  described  that  form  of  typhoid  fever  resem- 
bling malarial  fever  of  the  remittent  type  in  the  following  words  : 

"  From  beginning  to  end  the  patient  may  develop  no  symptom 
that  could  not  belong  to  this  disorder  (malarial  fever),  except  the 
persistence  of  fever  under  strongly  antimalarial  treatment  and 
the  occasional  occurrence  of  circumstances  that  point  to  a  typhoid 
origin.  There  is  no  intellectual  cloudiness  or  hebetude  of  expres- 
sion. Sleep  is  but  slightly  disturbed.  The  tongue  remains  moist 
and  coated  with  a  thin  whitish  or  yellowish  fur ;  the  appetite  per- 
sists very  often  in  some  degree.  There  is  almost  never  epistaxis. 
Constipation  is  commonly  observed,  diarrhoea  very  rarely.  There 
are  no  bloody  stools,  no  tympanites,  no  iliac  tenderness  or  gurgling. 
Rose  spots  are  much  more  often  absent  than  present.  The  patient 
can  be  restrained  in  bed  with  difficulty  or  under  protest.     Slight 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  83 

enlargement  of  the  spleen  may  occasionally  be  detected,  but  is 
more  frequently  not  observed.  More  severe  cases,  beginning  more 
or  less  abruptly,  develop  primarily  the  symptoms  of  remittent  fever, 
and  diagnostic  doubts  only  arise  when  the  absolute  resistance  to 
anti-periodic  treatment  and  the  gradual  appearance  of  typhoid 
symptoms  excite  suspicions  of  the  incorrectness  of  the  original 
diagnosis." 

(For  a  description  of  infectious  processes  complicating  typhoid 
fever,  see  further  on.) 

The  Course  of  the  Fever  in  Relation  to  Prognosis.  It  has 
already  been  pointed  out  that  fever  of  sudden  onset,  soon  followed 
by  a  fall  or  affected  by  marked  remissions  during  the  stage  of 
onset,  is  a  favorable  rather  than  an  unfavorable  omen.  A  some- 
what similar  statement  holds  true  in  regard  to  the  fever  of  the 
well-developed  disease  in  which  the  presence  of  persistently  high 
morning  and  evening  temperature,  the  variation  between  the  two 
being  but  slight,  possesses  an  evil  significance,  while,  on  the  other 
hand,  marked  differences  between  these  points  are  considered  of 
good  omen.  This  is  so  because  remissions  indicate  that  the  fever 
is  not  violent  and  because  remissions  permit  the  body  to  make 
repairs  to  enable  it  to  stand  another  rise,  whereas  the  constant 
maintenance  of  high  fever  seriously  impairs  the  vitality  of  the 
tissues.  This  temporary  reduction  of  fever  is  probably  one  of  the 
ways  in  which  the  cold  bath  does  good. 

In  regard  to  the  prognostic  value  of  high  temperatures  we  find 
considerable  unanimity  of  opinion.  Liebermeister,  in  studying 
400  cases,  found  that  of  those  whose  temperatures  rose  to  104° 
or  more  9.6  per  cent,  died  ;  of  those  whose  fever  exceeded  this 
degree,  29.1  per  cent,  died,  and  of  those  whose  axillary  tempera- 
ture exceeded  105.8°,  more  than  half  died.  Fiedler1  found  that 
when  the  temperature  reached  106°  more  than  half  died,  and 
Wuuderlich  states  that  at  106.1°  the  danger  is  considerable,  at 
107°  the  deaths  are  almost  twice  as  numerous  as  the  recoveries, 
and  at  107.2°  and  over  recovery  is  rare.    Concerning  the  influence 

1  Deutsches  Arch,  fur  klin.  Medicin,  Bd.  i.  p.  534. 


84       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

of  high  morning  temperatures,  Fiedler  says  that  practically  all 
patients  died  whose  morning  fever  rose  to  106.2°,  and  that  more 
than  half  died  if  their  morning  fever  reached,  if  only  once, 
105.4°. 

In  the  Maidstone1  epidemic  only  one  death  occurred  in  81 
cases,  the  temperature  of  which  reached  less  than  104°,  whereas 
nine  deaths  occurred  in  patients  who  had  fever  at  some  time  above 
104°,  but  a  case  is  recorded  of  recovery  after  a  temperature  of 
110°.2 

While  acute  hyperpyrexia  is  an  evil  omen  in  enteric  fever, 
long-continued,  moderately  high  fever  is,  perhaps,  more  harmful. 
In  the  Boylston  Prize  Essay  of  Harvard  University  for  1890  the 
writer  used  these  words  in  speaking  of  this  subject : 

"  Closely  allied  to  this  question  of  hyperpyrexia  is  that  which 
asks  us  to  define  what  we  mean  by  hyperpyrexia.  As  given  in 
most  works  on  fever,  this  term  is  applied  to  any  state  in  which 
the  temperature  reaches  106°  or  107°  F.  ;  but  in  reality  the 
figures  have  little  to  do,  except  in  an  indirect  way,  with  what 
student  or  physician  wishes  to  know.  A  temperature  of  106°  F. 
in  a  young  healthy  man  suffering  from  an  acute  attack  of  some 
short-lived  disease  does  not  mean  very  great  danger ;  but  a  tem- 
perature of  103°,  day  after  day  in  typhoid  fever,  does  mean 
danger,  and  must  be  carefully  attended  to.  In  simple,  continued 
fever  106°  F.  is  a  hyperpyrexia;  in  typhoid,  or  other  low  fever, 
103°  F.  is  a  hyperpyrexia.  The  question  is  not  one  of  actual  de- 
grees Fahrenheit,  but  rather  as  to  whether  the  temperature  present 
is  doing  any  harm." 

Very  great  differences  are  to  be  found  in  different  patients  in 
respect  to  the  persistency  of  high  fever  under  the  application  of 
hydrotherapy.  In  some  instances  active  bathing  serves  to  reduce 
the  fever  but  slightly ;  in  others  moderate  measures  produce  a 
marked  effect.  As  an  illustration  of  the  great  fall  produced  by 
sponging  with  ice-water  for  twenty  minutes,  with  active  friction, 

1  Poole.     Guy's  Hospital  Reports,  1898.     Wrongly  labelled  on  cover,  1896. 

2  St.  Thomas's  Hospital  Reports,  1895,  p.  248. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  85 

reference  may  be  had  to  the  following  chart  (Fig.  14),  in  which 
it  is  seen  that  as  great  a  fall  as  8°  F.  occurred.  One  is  tempted 
to  inquire  how  low  it  would  have  fallen  had  the  routine  method  of 
plunging  every  patient  sick  with  typhoid  fever  been  instituted. 
Yet  the  patient  was  an  unusually  heavily  built,  stalwart  lad  of 
twenty  years,  well  nourished,  and  in  good  condition  for  bathing. 
Further,  he  came  under  care  by  the  third  day  of  his  illness. 

Respiratory  System  in  the  Developed  Stage  of  the  Disease. 
The  respiratory  functions  of  patients  suffering  from  typhoid  fever 
are  not  materially  disturbed  unless  some  complicating  affection  of 
the  lungs  or  nearby  organs  develop.  Beyond  a  slight  quickening 
of  the  respirations,  varying  from  two  to  eight  a  minute,  as  the 
result  of  the  fever,  they  maintain  an  even  rhythm.  The  develop- 
ment, therefore,  of  rapid  or  noisy  breathing  is  indicative  of  some 
pulmonary,  cardiac,  or  renal  complication,  and  deserves  close 
scrutiny  and  study. 

Before  discussing  the  graver  respiratory  complications  of  this 
malady,  there  are,  however,  several  minor  facts  in  connection  with 
this  part  of  the  body  which  deserve  notice.  One  of  the  first  of 
these  is  the  curious  fact  that  coryza  is  almost  never  met  with  in 
typhoid  fever  in  any  of  its  stages,  and  its  presence  with  other 
signs  pointing  to  enteric  fever  stands  against  the  presence  of  this 
malady. 

Another  point  of  interest  is  the  frequency  of  epistaxis,  which 
is  chiefly  met  with  in  the  first  week  of  the  disease,  as  already 
pointed  out,  and  which  is  also  seen  quite  commonly  later  on,  prob- 
ably being  produced  in  most  instances  by  the  patient  picking 
the  nose  to  remove  crusts,  while  in  the  early  stages  it  is  a  means 
that  the  system  takes  for  relieving  the  frontal  headache  and  con- 
gestion which  are  so  common  at  that  time.  J.  M.  Da  Costa1  pre- 
sented in  a  recent  clinic  two  patients  who  had  this  symptom  late  in 
the  disease.  The  first  patient  had  been  ill  twenty-nine  days,  and 
his  temperature  had  reached  normal.  The  bleeding  was  violent, 
lasting  half  an  hour,  and  several  ounces  of  blood  were  lost.   Cerebral 

1  Medical  Fortnightly,  February  1,  1899. 


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Day  of  Dis. 

Pulse 

Resp. 

WELL  DEVELOPED  STAGE  OF  THE  DISEASE.  89 

symptoms  were  relieved,  and  the  man  made  good  progress  after- 
ward. The  second  patient  had  profuse  bleeding  during  the  fourth 
week  of  the  disease,  after  symptoms  of  typhoid  fever  had  practi- 
cally ceased.  Late  epistaxis  is  more  apt  to  occur,  in  Da  Costa's 
opinion,  after  severe  cerebral  symptoms,  which  are  thus  relieved. 
In  still  other  cases  the  hemorrhage  from  the  nose  is  part  of  the 
manifestation  of  a  general  hemorrhagic  diathesis.  Very  rarely  is 
the  symptom  excessive  enough  to  require  active  interference,  and 
still  more  rarely  does  it  cause  death.  Thus  out  of  1420  cases  seen 
by  Liebermeister,  epistaxis  took  place  in  107  cases,  but  death 
occurred  from  this  cause  in  only  two,  and  this  is  probably  a  high 
percentage. 

Perichondritis  of  the  larynx  complicating  typhoid  fever,  occurs 
in  less  than  1  per  cent,  of  all  fatal  cases,  and  Trousseau  has  pointed 
out  that  it  is  most  apt  to  occur  when  the  patient  suffers  from  pro- 
found exhaustion,  particularly  if  his  attack  has  been  a  prolonged 
one.  Schultz,  who  analyzed  4094  cases  of  typhoid  fever  which 
occurred  in  Hamburg  in  1886  and  1887,  does  not  record  any 
cases  of  perichondritis,  and  Jacob  does  not  mention  this  compli- 
cation. That  this  accident  may  be  due  to  the  local  action  of 
the  bacillus  of  Eberth  seems  to  be  vers-  probable,  and  Luca- 
tello1  believes  that  he  has  proof  that  it  is  the  cause  of  the  affec- 
tion. On  the  other  hand,  Dittrich2  asserts  that  the  process  is 
due  to  the  dorsal  position  of  the  patient,  and  is  more  directly  the 
result  of  the  pressure  of  the  laryngeal  cartilages,  particularly  the 
cricoid  rings  on  the  vertebral  column.  By  this  means  their  vitality 
is  impaired  and  their  invasion  by  pyogenic  micro-organisms  is 
rendered  easy.  Lemcke3  records  a  case  of  this  affection  occur- 
ring in  a  Swede  aged  twenty-four  years.  A  similar  case  has  been 
reported  by  Tooth,1  in  which  a  boy  of  five  years  suffered  from 
typhoid  fever  and  developed  on  the  eighteenth  day  of  his  illness 

1  Beitrag  ziir  Pathogenese  der  Kehlkopaffectionen  Beim  Typhus.    Berliner  klin. 
Woch.,  1894,  vol.  xxxi.  p.  379. 

-   Ilandbuch  diir  Spec.  Path,  und  Ther.,  Bd.  i.  p.  311. 

3  Chicago  Medical  Recorder  for  1897,  vol.  ii.  p.  114. 

4  London  Lancet,  April  2,  1893. 


90       COMPLICATIONS  AND  SEQUEL JE  OF  TYPHOID  FEVER. 

laryngeal  cough  and  aphonia.  Tracheotomy  was  performed  with- 
out relief.  The  cervical  glands  were  enlarged  and  death  finally 
occurred.  At  the  autopsy  the  larynx  and  trachea  were  found  lined 
with  diphtheritic  membrane.  Whether  this  was  due  to  the  bacillus 
of  Loeffler  or  to  the  bacillus  of  Eberth  is  not  stated.  Finally, 
Eppinger1  believes  that  the  ulcers  which  form  in  the  larynx  in 
typhoid  fever  are  slightly  analogous  to  the  ulcers  which  form  in 
the  intestines,  since  he  has  discovered  the  bacillus  of  typhoid  fever 
in  these  ulcers. 

In  an  inaugural  thesis  upon  ulcerations  of  the  larynx  in  typhoid 
fever,  Grader2  describes  three  types  of  this  disease.  In  one  of 
these  there  are  specific  ulcers  occurring  simultaneously  with  those 
in  the  bowel,  although  the  bacteriological  examinations  failed  to 
show  the  presence  of  the  specific  bacillus  in  these  ulcers.  Iu  the 
second  class  there  are  simple  catarrhal  manifestations  with  a  ten- 
dency to  ulceration.  Both  of  these  classes  involve  the  posterior 
wall  of  the  larynx  on  the  ary-epiglottic  fold.  The  third  class  is 
that  in  which  ulcers  formed  at  the  margin  of  the  epiglottis.  These 
usually  occur  singly. 

Laryngeal  ulceration  occurs  in  a  fairly  large  proportion  of  the 
severe  cases,  and  is  usually  due  to  secondary  infiltration  of  the 
laryngeal  mucous  membrane,  apart  from  true  typhoid  infection, 
arising  from  the  general  debility  of  the  patient.  Usually  these 
ulcers  form  at  the  posterior  part  of  the  larynx,  and  often  involve 
the  insertion  of  the  vocal  bands.  Under  these  circumstances  they 
may  cause  hoarseness  and  aphonia,  but  often  they  exist  if  in  mod- 
erate degree,  with  but  little  discomfort  to  the  patient.  Rarely  a 
painful  laryngeal  cough  develops,  and  if  they  extend  to  the  epi- 
glottis they  may  cause  pain  in  swallowing.  Contrary  to  what 
might  be  supposed,  they  rarely  lead  to  serious  difficulty,  nor  do 
they  materially  affect  the  course  of  the  disease.  Very  rarely  they 
produce  perichondritis  of  the  larynx  or  oedema  of  the  glottis. 
Hoffmann  found  laryngeal  ulcers  in  twenty-eight  cases  out  of  250 

1  Ziegler.     Path.  Anatomie,  Bd.  ii.  p.  626. 

2  Centralblatt  f.  Bacter.  und  Parasit.,  February  17,  1891. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  91 

typhoid  autopsies,  and  from  his  studies  it  is  evident  that  tins 
lesion  may  occur  in  the  second  week  of  the  disease.  Gricsinger 
found  them  in  26  per  cent,  of  the  cases  that  died,  and  that  the 
lesion  is  more  common  in  men  than  in  women.  These  statistics 
show  that  in  severe  cases  of  typhoid  fever  resulting  in  death  the 
laryngeal  lesions  are  more  commonly  present  than  is  generally 
thought,  and  illustrate  the  fact  already  pointed  out  that  unless 
the  ulceration  is  widespread  and  the  ulcers  involve  the  epiglottis 
and  vocal  bands,  no  marked  symptoms  of  laryngeal  trouble  may 
present  themselves.  On  the  other  hand,  in  166  cases  of  typhoid 
fever  Landgraf1  found  laryngeal  complications  to  be  rarely  pres- 
ent ;  in  some  instances  they  had  apparently  been  present  during 
the  early  stages  of  the  disease,  but  had  healed  before  death 
occurred.  Only  three  cases  of  perichondritis  and  two  cases  of 
muscular  paralysis  were  met  with,  the  latter  during  convalescence. 

(For  a  discussion  of  laryngeal  paralysis  see  the  chapter  on 
the  stage  of  convalescence.) 

An  interesting  case  of  so-called  laryngo-typhus  has,  however, 
been  recorded  by  Lewy2  as  occurring  in  a  child  of  one  year ; 
death  occurred  on  the  eighth  day,  and  the  autopsy,  in  addition  to 
revealing  the  intestinal  lesions  of  typhoid  fever,  also  showed  fibrin- 
ous laryngitis  and  croupous  pneumonia.  A  case  of  necrosis  of 
the  two  arytenoid  cartilages  has  also  been  reported  as  occurring 
in  a  man,  aged  eighteen  years,  by  Souques.3 

When  severe  laryngeal  disease  asserts  itself  the  condition  of  the 
patient  is  apt  to  become  at  least  pitiable,  and  it  may  be  alarming. 
The  largest  number  of  cases  collected  of  this  affection  are  those 
of  Liming,4  who,  in  1884  collected  213,  although  Keen,  in 
1876,  had  collected  169  cases.  Westcott,  in  collecting  statistics 
for  Keen's  well-known  monograph  on  the  Sun/teal  ( 'amplications 
of  Typhoid  Fever,  collected  thirty-eight  others.  Basing  his 
views  upon  his  statistics,  and  in  particular  upon  fourteen  original 

1  Deutscher  Medicmischer  Wochenschrift,  January  6,  1890. 

2  Archiv  fur  Kinderheilkunde,  Bd.  lx.,  heft.  3,  1888. 
:i  Bulletin  de  la  Societe  Anatomique. 

1   Archiv  fur  klin.  Chirurgie,  1884,  vol.  xxx.  \>.  225. 


92       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

cases,  Liming  gives  the  following  graphic  word-picture  of  the 
conditon  : 

"Physician  and  patient  together  rejoice  over  the  daily  progress 
toward  convalescence  ;  of  the  still  slight  but  persistent  trouble 
in  the  throat,  scarcely  a  word  is  said,  until  all  at  once — an  expo- 
sure to  cold,  a  little  walk,  is  then  usually  blamed  for  it — the 
hoarseness  increases,  and  swallowing  becomes  markedly  painful. 
The  picture  now  quickly  alters.  Soon,  often  within  a  few  hours, 
come  dyspnoea  and  suffocating  attacks.  Sometimes  even  during 
the  very  first  day  the  anxious  scene  of  laryngeal  stenosis  sets  in, 
with  stridor,  inspiratory  depression  of  the  neck  and  chest-wall — 
the  unrest  of  despair,  a  struggle  with  death.  The  face  becomes 
livid ;  the  respiration  becomes  rapid,  wearisome ;  the  auxiliary 
muscles  of  respiration  are  all  called  into  play ;  sometimes  the 
respirations  are  prolonged  and  noisy.  The  patient  can  find  no 
rest ;  the  dyspnoea  even  prevents  the  taking  of  nourishment ;  the 
expectoration  of  the  increasing  mucus  becomes  imperfect ;  soon 
attacks  of  suffocation  recur.  Either  a  tracheotomy  must  now  be 
done  immediately,  or  the  patient,  if  he  is  weak,  may  choke  to 
death,  even  in  the  first  attack.  More  commonly,  however,  the 
attack  subsides,  and  a  slight  improvement  with  a  short  sleep  will 
ensue.  Expectoration  of  bloody  mucus,  masses  of  pus,  and,  in 
some  cases,  even  of  pieces  of  cartilage,  diminish  the  symptoms, 
and  show  at  the  same  time  that  the  real  cause  of  the  dyspnoea  is 
not  a  catarrhal  oedema  or  dropsical  swelling,  but  a  destructive 
ulceration,  even  of  the  cartilages.  Often,  also,  there  is  severe 
fever.  Thus  pass  on,  it  may  be,  even  days  and  weeks,  easy 
breathing:  alternating;  with  the  suffocative  attacks.  The  alterna- 
tive  is  only  a  finally  fatal  attack  of  suffocation,  or  a  late  palliative 
tracheotomy  with  all  its  uncertainties.  ...  If  one  will  read 
the  cases  of  death  from  suffocation  without  operation  (52  cases, 
49  deaths),  he  will  find  that,  almost  without  exception,  suffocation 
occurred  early  arid  quickly,  before  either  physician  or  patient 
had  even  thought  of  tracheotomy. 

"  This  is  the  picture  in  cases  of  perichondritis.  If  the  patient 
is  in  the  stage  of  typhoid  stupor,  when  the  ulceration  is  accompa- 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  93 

nied  with  acute  suppuration  and  swelling  which  may  lead  to 
destruction  of  the  cartilages,  the  initial  symptoms  of  the  threat- 
ening danger  may  escape  us  entirely  in  spite  of  careful  observa- 
tion. ...  In  these  cases  the  objective  signs  of  laryngeal 
stenosis,  on  which  we  usually  depend,  are  much  less  marked  ; 
stridor,  movements  of  the  larynx,  inspiratory  depression,  action 
of  the  auxiliary  inspiratory  muscles — in  short,  everything  by 
which,  in  the  healthy,  we  make  the  diagnosis  of  narrowing  of  the 
air-passages  is,  in  the  vita  minima  of  the  weakened  patient,  far 
less  outspoken,  and  easily  deceives  us  as  to  the  degree  of  the 
danger  of  suffocation.  The  striking  suffocative  attacks,  with 
arrest  of  respiration,  so  alarming  even  to  the  lay  observer,  are 
less  noticeable,  since  the  struggle  of  the  patient  with  the  mechan- 
ical obstruction  quickly  fails  or  is  quickly  abandoned.  The  con- 
dition passes  into  a  death  agony  with  oedema  of  the  lungs,  with- 
out the  stenosis  seeming  to  have  reached  a  threatening  degree. 
And  thus  one  sees,  often  with  astonishment,  in  the 
reports  of  the  necropsies,  how  often  the  stenosis  and  destruction  of 
the  cartilages  occur,  as  it  were,  '  without  even  any  symptoms.'  ' 

Liming' s  statistics  seem  to  show  that  severe  laryngeal  ulceration 
is  far  more  frequent  in  Germany  than  in  England  or  America, 
and  in  the  latter  country  it  must  be  very  rare. 

Keen's  essay  points  out  that  emphysema  and  suppuration  of 
the  mediastinum  may  follow  perforative  ulceration  of  the  larynx, 
and  Wilks1  records  the  case  of  a  patient  of  twelve  years,  who  on 
the  twelfth  day  of  the  disease  developed  general  emphysema 
due  to  this  cause.  Denhanr  records  a  similar  case  in  a  boy  of 
ten  years,  and  Chomel3  another  in  a  man  of  twenty  years,  from  a 
perforation  of  the  thyroid  cartilage.  One  instance  is  recorded 
by  Luning  in  which  an  abscess  had  destroyed  the  arytenoids  and 
rendered  the  cricoid  necrotic,  so  that  the  anterior  mediastinum 
was    filled  with    pus,   and  Retslay4  records    another   in  which   a 

1  Medical  Times  and  Gazette,  1862,  vol.  ii.  p.  276. 

2  Holmes'  System  of  Surgery,  2d,  ed.,  vol.  iv.  p.  571. 
15  These  de  Paris,  1877. 

4  Retslay,  Ueber  Perichrondritis  Laryngva  Berlin,  Dissert.  1870,  No.  10. 


94       COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER. 

perichondral  abscess  about  the  thyroid  cartilage  caused  secondary 
involvement  of  the  anterior  and  posterior  mediastinum. 

Keen's  table  shows  that  in  146  cases  of  severe  laryngeal  dis- 
ease 12  occurred  under  fifteen  years,  87  between  fifteen  and 
twenty-five   years,  and  47  over  twenty-five  years. 

The  marked  exemption  of  children  is  evidently  associated  with 
the  mild  character  of  the  disease  in  this  class  of  patients.  Lim- 
ing's  table  of  165  cases  showed  18  under  fifteen  years,  109 
between  fifteen  and  twenty-five  years,  and  28  between  twenty-five 
and  thirty  years,  and  10  between  thirty  and  thirty-five  years  or 
over,  giving  results  of  a  similar  character.  The  far  greater  fre- 
quency of  the  malady  in  men  than  in  women  is  interesting,  for  in 
the  female  the  general  disease  is  as  severe  as  in  males,  as  a  rule, 
yet  in  Keen's  table  there  were  119  males  to  29  females,  and  in 
Liming' s  table  129  males  to  36  females.  Keen  tells  us  in  regard 
to  the  date  of  onset  that  7  cases  occurred  in  the  first  week,  23 
in  the  second,  30  in  the  third,  and  82  in  the  fourth  week  to  two 
months. 

Keen  states  that  necrosis  of  the  cartilages  is  by  far  the  most 
common  and  also  by  far  the  most  dangerous  form  of  laryngeal 
affection,  but  adduces  no  evidence  in  support  of  its  being  the 
most  common  lesion.  Opposed  to  this  view  we  have  that  of 
Liebermeister,  who  tells  us  that  "laryngeal  ulcers  do  not  in 
any  way  affect  the  ordinary  course  of  the  disease,  and  in  favor- 
able cases  heal  without  leaving  any  evil  consequences."  "  Occa- 
sionally," he  tells  us,  "they  may  lead  to  death  by  producing 
perichondritis  laryngea  or  glottic  oedema."  This  difference  of 
opinion  rests  upon  a  difference  in  the  severity  of  the  lesions. 
Surgeons  only  meet  with  cases  which  are  severe  enough  to  demand 
operative  relief,  whereas  physicians  comparatively  commonly  see 
the  milder  forms.  When  necrosis  of  the  cartilage  does  take  place 
there  can  be  no  doubt  that  Keen's  statement  as  to  the  danger 
being  great  is  correct,  for  in  this  condition  his  statistics  show 
that  the  mortality  approximates  95  per  cent.  In  197  cases  of 
laryngeal  stenosis  in  enteric  fever  Keen  records  a  mortality  of 
67  per  cent.,  which  if  the  cases  are  divided  into  those  operated 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  95 

on  by  tracheotomy  equals  55.5  per  cent.,  and  not  operated  on, 
78.6  per  cent.  That  operation  is  imperative  as  soon  as  suffoca- 
tive attacks  are  threatened,  is  evident. 

The  bronchitis  of  advanced  typhoid  fever  is  a  very  constant 
symptom,  so  constant  that  it  really  forms  part  of  the  symptom- 
complex  of  the  regular  disease.  It  is  only  when  it  becomes  severe 
and  passes  into  a  broncho-pneumonia  that  it  possesses  any  consid- 
erable interest,  for  if  at  all  well  developed  it  becomes  a  grave 
menace  to  the  patient's  life.  This  lobular  pneumonia  depends 
upon  four  separate  causes  for  its  existence.  First,  the  bronchial 
irritation  characteristic  of  the  disease ;  second,  the  feeble  respira- 
tory movements  of  the  patient,  and  the  dorsal  decubitus  whereby 
dependent  portions  of  the  lung  collapse ;  third,  the  feeble  circu- 
lation which  permits  stasis  in  the  pulmonary  vessels  ;  and,  finally, 
and  very  important,  the  inspiration  into  the  lungs  of  particles  of 
food  or  foreign  bodies  in  the  mouth  or  nose  which  are  septic,  or 
which  decompose,  and  produce  pneumonia  in  this  manner.  The 
physical  signs  of  this  form  of  the  diesase  are  identical  with  those 
of  ordinary  lobular  pneumonia,  and  the  prognosis  is  bad  in  direct 
proportion  to  the  feebleness  of  the  heart  and  general  system,  the 
extent  of  the  lesion,  and  the  slowness  with  which  the  heart  and 
general  system  responds  to  stimulation.  Hoffmann  tells  us  that 
this  complication  was  found  38  times  in  250  autopsies  ;  so  it  is 
evident  that  its  influence  in  producing  a  fatal  result  is  probablv 
not  very  great,  as  a  rule.  It  is  emphatically  a  symptom  pertain- 
ing to  feeble  and  debilitated  patients,  and  most  often  comes  on  in 
the  latter  part  of  the  second  or  third  week.  As  is  often  the  case 
lobular  pneumonia  may  afford  a  favorable  field  for  the  growth 
of  the  bacillus  tuberculosis,  and,  therefore,  in  those  cases  in  which 
resolution  does  not  take  place,  pulmonary  phthisis  not  infre- 
quently follows  this  form  of  the  disease.  Mettcnheimer1  saw 
thirteen  cases  of  this  character  out  of  thirty-eight  deaths  from 
typhoid  fever  or  its  sequela?. 

1  Beobacbtungen  ueber  die  typhoiden  Erkrankungen  der  franzosischen  Konigs- 
gefangenen  in  Scbwerin,  Berlin,  1879. 


96       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

Very  much  more  rarely  acute  miliary  tuberculosis  develops  in 
typhoid  fever,  probably  because  the  focus  of  some  earlier  and 
dormant  tubercular  infection  breaks  down  and  sets  free  tubercle 
bacilli  in  a  system  the  vitality  of  which  is  depressed.  Hoffmann 
found  it  four  times  in  250  typhoid  fever  autopsies. 

Hypostatic  congestion  of  the  lungs,  a  condition  closely  allied  in 
causation  and  prognosis  to  lobular  pneumonia,  occurred  in  100 
out  of  1420  cases  recorded  by  Liebermeister,  and  pulmonary 
oedenia  is  the  usual  immediate  cause  of  death  in  cases  which  die 
of  failure  of  the  cardiac  muscle,  as  Hoffmann  has  proved. 

True  croupous  pneumonia  occurring  in  the  later  stages  of  typhoid 
fever,  either  as  a  result  of  an  infection  with  the  micrococcus  lan- 
ceolatus  or  by  the  bacillus  of  Eberth,  is  a  very  rare  affection,  much 
more  rare  than  it  is  in  the  stage  of  onset  as  already  pointed  out. 
Hoffmann  found  it  present  only  eighteen  times  in  250  typhoid 
autopsies.  Again,  in  1420  cases  quoted  by  Liebermeister,  52  cases 
had  "  extensive  consolidation "  of  the  lung  not  dependent  on 
hypostatic  congestion.  A  "  good  many  "  of  these,  however,  were 
probably  cases  of  true  lobular  pneumonia  and  were  not  croupous. 

In  this  connection  it  is  interesting  to  note  that  as  long  ago  as 
1839  Becquerel  wrote  an  article  on  pneumonia  complicating 
typhoid  fever  when  making  an  analysis  of  eighteen  cases  in  the 
service  of  Jadelot  in  1837. 

Hemorrhagic  infarction  of  the  lungs  arises  in  typhoid  fever 
from  several  causes,  and  is  usually  met  with  in  cases  with  greatly 
impaired  circulation.  It  is  due  to  emboli  arising  in  the  right  side 
of  the  heart  or,  very  rarely,  to  emboli  arising  from  a  phlebitis. 
(See  circulation  in  convalscence.) 

It  has  been  suggested  that  it  may  arise,  when  septic,  from  the 
intestinal  ulcers,  but  no  case  of  this  kind  has  come  to  my  notice. 

Sometimes  it  may  arise  from  a  bed-sore,  a  parotid  abscess,  or 
or  from  an  abscess  elsewhere. 

In  many  cases  the  presence  of  small  infarctions  is  unsuspected, 
either  because  they  cause  little  difficulty  or  because  they  are  not 
differentiated  from  lobular  pneumonia,  the  physical  signs  in  each 
case  being;  nearlv  identical.    "When  the  infarction  is  large  we  have 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  97 

a  rise  of  temperature,  pain  in  the  chest,  currant- jelly  Mood  in  the 
sputum  and,  if  the  embolus  is  septie  and  the  patient  survives 
signs  of  pulmonary  abscess  or  gangrene.  Sometimes  the  infarc- 
tion is  due  to  thrombosis.  The  presence  of  a  focus  which  can 
supply  an  embolus  and  of  a  feeble  heart,  increase  the  probability 
of  the  pulmonary  difficulty  being  infarction,  and  an  infarction 
severe  enough  to  be  recognized  is  of  evil  prognostic  omen.  Out 
of  250  typhoid  autopsies  Hoffmann  found  fifteen  cases  of  hemor- 
rhagic pulmonary  infarction. 

Haemoptysis  complicating  typhoid  fever  in  a  patient  free  from 
tuberculosis  may  occur.  Creagh1  has  reported  such  an  instance  in 
a  man  of  thirty-five  years  ;  the  accident  resulted  in  death.  Unfor- 
tunately, no  autopsy  was  made  in  this  case  to  prove  that  there 
was  no  local  tubercular  lesion  ;  but  it  is  possible  that  such  hemor- 
rhages may  occur  without  tuberculosis. 

Primary  pleurisy  complicating  typhoid  fever  is  very  rare. 
Nearly  always  it  is  secondary  to  infarction,  pneumonia,  or  gan- 
grene. Rarely  it  may  be  due  to  direct  typhoid  infection,  and 
when  this  is  the  case  the  effusion  is  usually  purulent.  As  early  as 
1885  Rendu  and  de  Gennes,2  and  in  1887  A.  Fraenkel3  obtained 
the  bacillus  of  Eberth  from  the  pus  of  an  empyema.  In  Keen's 
essay  Westcott  has  collected  nine  instances  of  typhoid  pleural 
effusion,  in  five  of  which  this  specific  organism  was  found.  As  a 
rule,  this  state  comes  on  as  a  late  symptom,  not  earlier  than  the 
third  week,  or  sometimes  not  until  two  months  after  the  fever. 

Further,  in  support  of  the  statement  as  to  the  secondary  char- 
acter of  pleurisy,  out  of  these  nine  cases  it  succeeded  pneumo- 
thorax once,'  pulmonary  abscess  once,5  gangrene  of  the  lung 
once,G  and  suppurative  mediastinitis  once.7 

1  London  Lancet,  November  30,  1895. 

2  La  France  Med.,  1885,  vol.  ii.  p.  1821. 

3  Verhandlungen  Sechste  Kongress  fur  Inner.  Med.,  1887,  p.  179. 
*  Rendu.     La  France  Mddicale,  1885,  vol.  ii.  p.  1809. 

5  Ramsey.      Annals  of  Surgery,  .January,  1890,  p.  39. 

6  Griesinger.     Infectionskrankheiten, 

7  Barr.     Liverpool  Medico-Chirurgical  Journal,  L893,  vol.  xiii.  p.  346. 


98       COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

The  prognosis  is  apparently  very  good,  as  six  of  these  nine 
cases  recovered  after  aspiration  or  drainage,  including  that  with 
pus  in  the  mediastinum. 

Empyema  due  to  the  streptococcus,  occurring  in  the  course  of 
typhoid  fever,  is  also  reported  by  Hanquet.1 

A  case  of  empyema  complicating  relapse  in  typhoid  fever,  in 
the  pus  of  which  typhoid  bacilli  were  found  in  large  numbers,  has 
been  recorded  by  Valentine.2 

A  case  of  gangrene  of  the  lung  in  a  boy  of  eight  years,  occur- 
ring as  a  sequel  to  typoid  fever  has  been  recorded  by  Acker.3 
Death  occurred. 

Circulation  in  the  Developed  Stage  of  the  Disease.  The 
development  of  fever  in  enteric  infection  is  accompanied  by  an 
acceleration  of  the  pulse-rate,  as  it  is  in  all  maladies.  With 
the  onset  of  the  disease  the  heart,  not  yet  weakened  by  illness, 
may  not  only  greatly  quicken  its  beat,  but  also  cause  the  pulse 
to  be  more  strong  than  normal.  As  the  disease  progresses,  how- 
ever, the  pulse  becomes  weaker  and  weaker  in  severe  cases, 
and  the  heart-sounds  more  and  more  feeble  till  they  may  be 
inaudible  even  with  the  most  careful  auscultation.  With  the 
ordinary  quickening  of  the  pulse  and  its  common  alterations  we 
have  little  to  do  at  this  point.  The  points  that  interest  us  are 
the  unusual  variations,  which  consist  chiefly  in  dicrotism,  tachy- 
cardia, bradycardia,  and  intermittence,  relaxation  of  the  vascu- 
lar pathways  on  the  one  hand,  and  aberrant  action  of  the  heart 
as  to  force  and  sounds  on  the  other.  Dicrotism  may  be  present 
for  days  at  a  time  in  feeble  cases,  and  is  an  unfavorable  sign  of 
not  great  gravity  unless  associated  with  other  grave  symptoms. 
Ordinarily  pulse-rates  varying  between  80  to  120  can  be  regarded 
by  the  physician  with  equanimity,  although  much  depends  upon 
the  character  of  the  pulse,  and. still  more  upon  the  quality  of  the 
heart-sounds,  which  should  always  be  studied  in  connection  with 
the  pulse.    With  each  ten  additional  beats  the  gravity  of  the 

1  Archives  Medicale  Beiges,  June,  1892. 

2  Berliner  klin.  Wochenschrift,  1889,  No.  15. 

3  Archives  of  Pediatrics,  September,  1896. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  99 

condition  greatly  increases,  and  if  a  pulse  rises  to  140  or  150  per 
minute  without  some  momentary  exciting  cause,  and  remains  so 
rapid,  the  condition  is  indicative  of  doubtful  recovery.  If  at  the 
same  time  there  is  coldness  of  the  extremities,  independent  of 
contact  with  ice-bags  or  other  extraneous  causes,  dissolution  may 
be  imminent.  Much  depends,  however,  upon  the  quality  of  the 
pulse- wave.  If  it  is  full  and  possesses  an  approximately  normal 
tension,  the  danger  is  less  grave  than  if  it  is  gaseous  and  relaxed 
and  easily  extinguished.  Sometimes  auscultation  of  the  heart  will 
show  that  it  is  acting  strongly  yet  pumping  futilely  in  an  attempt 
to  fill  relaxed  and  dilated  vessels. 

It  has  been  asserted  by  some  clinicians  that  much  prognostic 
information  can  be  gained  from  the  heart-sounds  in  typhoid  fever. 
Thus  Landouzy,  Picot,  Huchard,  and  others  have  formulated  this 
conclusion,  namely,  that  the  disappearance  of  the  first  sound  of 
the  heart  at  the  apex  or  at  the  base  in  the  course  of  typhoid  fever 
constitutes  an  evil  sign  if  the  pulse  goes  as  high  as  110,  and  that 
if  the  sound  be  absent  and  the  pulse-rate  increases  in  excess  of 
this  number  per  minute,  the  prognosis  is  fatal.  Of  course,  any 
condition  of  profound  depression  in  the  heart  or  general  strength 
which  can  extinguish  the  first  sound  is  more  or  less  grave,  but 
the  association  of  this  disappearance  with  high  pulse-rate  they 
consider  a  very  evil  omen.  Mongour1  has  recently  written  a  con- 
firmatory paper  on  this  theme. 

In  still  other  instances  the  heart-sounds  are  like  those  of  a 
foetus,  the  loug  pause  being  absent.  This  is  called  "  embryocar- 
dia,"  and  indicates  distinct  cardiac  feebleness. 

These  circulatory  changes  have  been  chief! v  discussed  bv  French 
clinicians.  Bernheim2  has  described  a  variety  of  typhoid  fever 
that  lie  calls  "forme  eardiaque,"  the  chief  signs  of  which  are  a 
eonditioD  of  asystole  and  cardiac  feeblenees.  Demange3  has  also 
written   on   this  topic,  and   Potain    is  quoted   by  Homolle   in   his 

1  La  Presse  Medieule,  April  21,  1897. 

-  Association  pour  1' A vancement  des  Sciences  ;  Conures  de  hi  Rochelle,   1V^'J. 

■   Revue  de  Me'decin,  1885,  p.  1025. 


100     COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER. 

article  on  typhoid  fever,  in  Jaeeoud's  Dictionnaire,  as  having 
found  a  constant  decrease  of  arterial  pressure  by  means  of  the 
sphygmomanometer  of  Basch.  This  reduction  of  pressure  is  an 
almost  constant  symptom,  as  every  one  knows  who  has  studied 
the  pulse  of  patients  suffering  with  this  disease. 

In  other  cases,  which  are  rare,  comparatively  speaking,  the 
pulse-rate  remains  at  or  below  the  normal  all  through  the  attack. 
This  is  without  any  particular  import,  and  was  thought  by  the 
older  writers,  such  as  Hufeland,  Sauvages,  and  Berndt,  to  be 
quite  pathognomonic  of  this  disease.  Liebermeister  states  that  a 
good  pulse  in  typhoid  fever  rarely  rises  above  110. 

If  the  circulation  distinctly  fails,  congestion  of  the  veins  may 
develope,  but  the  surface  of  the  body  instead  of  becoming  cyanotic 
or  congested  in  appearance,  often  becomes  pallid  and  relaxed,  a 
profuse  sweat  often  being  present,  even  though  the  temperature 
may  be  as  high  as  104°. 

Over  and  above  these  gradual  signs  of  circulatory  failure,  sud- 
den collapse  from  hemorrhage  or  perforation  may  develop.  (See 
article  on  alimentary  canal.)  A  sudden  diarrhoea  or  an  attack 
of  vomiting  may,  however,  cause  a  syncopal  attack,  and  a  sud- 
den fall  of  high  temperature  due  to  some  complicating  state 
may  also  do  so.  Liebermeister,  though  an  ardent  advocate  of  the 
cold  bath,  says  :  "  Sometimes  a  condition  resembling  collapse  is 
seen  to  follow  a  cold  bath."  So  far  as  prognosis  is  concerned, 
care  should  be  taken  to  separate  the  collapse  of  defervescence 
from  that  due  to  grave  cardiac  degeneration.  (For  circulatory  acci- 
dents see  chapter  on  the  circulatory  system  in  the  stage  of  con- 
valescence.) 

Acute  endocarditis  complicating  typhoid  fever  has  been  reported 
by  Carbone.1  The  patient  was  a  young  women  avIio  had  the  classi- 
cal symptoms  and  lesions  of  typhoid  fever,  and  from  whose  endo- 
cardium typhoid  bacilli  were  obtained.  These  bacilli  were  injected 
intravenously  in  various  animals,  producing  the  same  lesion. 

ConnelP  has  also  recorded  a  case  of  infectious  endocarditis  in 

1  Gazette  Medica  di  Torino,  No.  23,  1892. 

2  Montreal  Medical  Journal,  August,  1896. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  101 

typhoid  fever,  due  to  the  staphylococcus  and  involving  the  mitral 
and  tricuspid  valves. 

In  connection  with  this  subject,  it  may  be  proper  to  call  atten- 
tion to  the  profound  exhaustion  and  depression,  chiefly  manifested 
at  the  close  of  severe  typhoid  fever,  having  a  tendency  to  cause 
death  from  asthenia.  This  state  was  far  more  frequently  met  with 
some  years  ago,  when  the  infection  seemed  more  virulent  than  it 
does  to-day,  and  when  the  treatment  was  not  so  well  understood. 
The  condition  of  the  patient  has  been  described  by  Huxham  in 
his  Essay  on  Fevers,  17  •">(),  p.  78,  in  the  following  words  : 

"  Now  Nature  sinks  apace,  the  extremities  grow  cold,  the  nails 
pale  and  livid,  the  pulse  may  be  said  to  tremble  and  flutter  rather 
than  to  beat,  the  vibrations  being  so  exceedingly  weak  and  quick 
that  they  can  scarce  be  distinguished,  though  sometimes  they  creep 
on  surpisingly  slow,  and  very  frequently  intermit.  The  sick 
become  quite  insensible  and  stupid,  scarce  affected  with  the  loud- 
est noise  or  the  strongest  light,  though  at  the  beginning  strangely 
susceptive  of  the  impressions  of  either.  The  delirium  now  ends 
in  a  profound  coma,  and  that  soon  in  eternal  sleep.  The  stools, 
urine,  and  tears  run  off  involuntarily,  and  announce  a  speedy  dis- 
solution, as  the  vast  tremblings  and  twitchings  of  the  nerves  and 
tendons  are  preludes  to  a  general  convulsion,  which  at  once  snaps 
off  the  thread  of  life.  In  one  or  other  of  these  ways  are  the  sick 
carried  off,  after  having  languished  on  for  fourteen,  eighteen,  or 
twenty  days,  nay,  sometimes  for  much  longer." 

The  Blood  in  the  Developed  Stage  of  Typhoid  Fever.  In 
typhoid  fever  in  the  first  two  weeks  of  the  disease  we  usually  find 
little  if  any  change  in  the  red  corpuscles,  unless  an  active  diarrhoea 
be  present,  in  which  case  there  may  be  concentration  <  >f  the  blood- 
cells.  In  the  third  week  the  red  cells  begin  to  decrease,  and  may 
get  as  low  as  in  eases  of  pernicious  anamiia.  The  lowest  point  is 
reached  about  the  end  of  the  first  week  of  convalescence,  when 
they  gradually  begin  to  increase.  The  haemoglobin  follows  the 
red  cells,  as  might  be  expected,  and  the  degree  of  the  anaemia  is 
in  direct  proportion  to  the  severity  of  the  ease  in  most  instances. 
The  most    noteworthy  fact    about    the   blood  in  this  fever   is   that, 


102     COMPLICATIONS  AND  SEQUEL  JE  OF  TYPHOID  FEVER. 


as  rule,. there  is  no  constant  increase  in  the  leucocytes  unless  some 
intercurrent  inflammation  is  set  up.  Cabot  asserts,  however,  that 
sometimes  leucocytosis  does  occur  without  any  complication  that 
can  be  found.  On  the  other  hand,  in  patients  profoundly  asthenic 
from  this  disease  complications  may  not  cause  leucocytosis.  As  an 
illustration  of  the  manner  in  which  these  accidents  may  produce 
blood  changes,  the  following  table  of  Cabot  is  of  interest : 


Perforation. 


Phlebitis. 


Otitis  media. 


Leucocytes 

Case  I    (a). 

Five  days  before  perforation 

8,300 

(6). 

At  time  of  perforation    . 

24,000 

Case  II. 

At  time  of  perforation 

18,500 

Case  I    (a). 

Two  days  before  onset 

6,400 

(6). 

At  time  of  onset 

12,900 

(c). 

One  week  later 

10,100 

Case  II  (a). 

One  week  before  onset 

4,800 

(6). 

At  time  of  onset 

16,200 

Case  I    (a). 

At  entrance     . 

5,300 

(b). 

Mastoid  abscess 

16,400 

Case  II  (a). 

At  entrance     . 

8,400 

(6). 

Two  weeks  later,  after  opening 

drur 

a 

membrane  (sero-purulent  disc 

large 

)    11,200 

Caselll  (a). 

At  entrance     . 

.       7,320 

(b). 

Otitis 

.     14,000 

A  freely  discharging  otitis  soon  ceases  to  cause  leucocytosis — e.  g., 
a  case  of  serous  otitis  media  seven  days  after  puncture,  but  still  dis- 
charging freely,  showed  but  5320  white  cells  per  cubic  millimetre. 

An  abscess  of  the  buttock  raised  the  count  from  8000  to  11,200, 
and  a  hemorrhage  from  8000  to  11,300. 

As  with  all  inflammations,  it  is  the  increase  in  the  polymorpho- 
nuclear cells  which  is  chiefly  indicative. 

The  real  value  of  discovering  alterations  in  the  blood  in  typhoid 
fever  is  very  great  for  diagnostic  purposes.  Increased  leucocytosis 
will  give  us  reason  to  believe  that  there  is  present,  and  make  us 
search  for,  some  complicating  inflammatory  focus,  such  as  pneu- 
monia, perforation,  cholecystitis,  phlebitis,  or  abscess  in  any  part 
of  the  body,  as  in  the  liver.  Further,  it  niay  render  a  case  of 
suspected  typhoid  fever  clearly  one  of  appendicitis  or  some  other 
inflammatory  affection. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  103 

The  study  of  leucocytosis  is  useless  to  us  in  separating  malarial 
fever  from  typhoid  fever,  for  in  neither  affection  does  it  occur,  and 
the  same  statement  holds  true  as  to  tuberculosis  unless  the  latter  is 
accompanied  by  coincident  infections  with  pus  organisms,  when 
leucocytosis  may  be  present.1 

The  blood  in  typhoid  fever  should  not  be  examined  after  a  bath, 
as  this  may  cause  a  temporary  leucocytosis  in  the  peripheral  vessels. 

The  bacillus  of  Eberth  is  very  rarely  found  in  the  blood,  but  a 
recent  case  of  interest  lias  been  reported  by  De  Grandmaison  and 
Cartier.2  They  report  the  case  of  a  woman  who  was  admitted  to 
the  hospital  suffering  from  the  results  of  an  abortion,  who  pre- 
sented typical  typhoid  symptoms,  and  whose  blood  gave  the  posi- 
tive Widal  reaction,  and  from  whose  blood  they  obtained  pure 
cultures  of  the  bacillus  of  Eberth. 

The  Spleen.  The  changes  produced  in  the  spleen  are  usually 
developed  during  the  fourth  week  of  the  disease.  Hoffmann  found 
nine  cases  of  infarction  of  this  organ  in  250  autopsies,  and  seven  of 
these  died  in  the  fourth  week.  Griesinger  believed  infarction  of  the 
spleen  to  be  found  in  7  per  cent,  of  fatal  cases,  and  Liebermeister 
believed  these  lesions  to  be  responsible  for  the  production  of  peri- 
tonitis in  many  cases  where  this  condition  arises  independently  of 
perforation.  Sometimes  the  infarction  results  in  the  formation  of 
a  large  abscess  filling  the  greater  part  of  the  organ.  Liebermeister 
records  a  case  in  which  after  death  from  general  peritonitis  the 
spleen,  which  was  three  times  its  natural  size,  was  found  trans- 
formed into  a  huge  abscess,  making  seven-eighths  of  its  bulk.  Xo 
perforation  of  the  abscess  wall  had  occurred. 

Under  the  name  spleno-typhoid,  Eiselt3  has  described  a  condi- 
tion in  which,  according  to  his  description,  the  spleen  bears  the 
brunt  of  the  affection  and  the  intestinal  complications  are  absent. 

1  Valuable  studies  of  these  questions  are  those  of  Cabot,  from  whose  l.mok  on 
the  blood  I  have  quoted,  and  those  of  Thayer,  Johns  Hopkins  Hospital  Reports, 
vol.  iv.  p.  83.  Also  Ouskow  and  Aporti  and  Radaeli,  Eleventh  Congress  for 
Medical  Science,  Rome,  March,  IS',14. 

2  La  Presse  Medicale,  February  1,  1899. 

3  La  Semaine  Mgdicale,  August  27,  1891. 


104     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

The  spleen  may  be  very  much  enlarged  and  there  may  be  a  peri- 
splenitis with  adhesions.  In  another  form  the  spleen  becomes 
enormous  in  size,  with  effusions  into  the  splenic  pulp  accompanied 
by  high  fever  lasting  for  several  weeks,  and  in  the  third  variety 
the  spleen  is  not  so  large,  but  the  fever  is  a  very  early  symptom. 
In  this  type  a  relapsing  fever  occurs,  but  Eiselt  asserts  that  spirilla 
of  Obermeier  have  not  been  found  in  the  blood  in  these  cases  and 
that  they  are  truly  typhoid,  because  of  the  intestinal  lesions  found 
in  some  of  the  fatal  cases  in  the  latter  forms  of  the  disease  and 
by  reason  of  the  source  of  infection. 

The  Genito -urinary  Tract  in  the  Well-developed  Stage  of 
the  Disease.  It  has  already  been  pointed  out  in  an  earlier  chapter 
that  acute  nephritis  may  usher  in  an  attack  of  typhoid  fever,  but 
such  an  occurrence  is  very  uncommon,  and  the  development  of  a 
nephritis  in  the  later  stages  of  the  disease  is  almost  as  rare.  In 
such  a  case  the  presence  of  albumin,  casts,  blood-cells,  and,  per- 
haps, pure  blood  may  make  a  diagonsis  easy. 

Curiously  enough  the  amount  of  blood  in  the  urine  in  such 
cases  is  no  guide  to  their  severity,  because  unless  the  flow  of  blood 
has  been  sufficiently  great  to  decrease  the  patient's  strength  it  does 
not  represent  the  degree  of  renal  involvement.  Further,  it  is  to 
be  remembered  that  in  some  cases  in  which  there  is  marked  hserna- 
turia,  the  autopsy  fails  to  reveal  marked  renal  change,  or  instead 
of  nephritis  an  infarction.  Such  cases  have  been  reported  by  Hom- 
burger  and  by  Duckworth,  by  Sorel,  and  by  other  writers.  In 
cases  in  which  there  are  tube  casts  and  other  signs  of  acute  diffuse 
nephritis,  the  prognosis  may  be  grave.  Osier  reports  two  cases 
which  died.  Amat  had  ten  deaths  in  twelve  cases,  while  Wagner 
had  five  consecutive  recoveries. 

Hemorrhagic  nephritis  has  been  recorded  by  Stevens1  in  associ- 
ation with  ursemic  symptoms.  Relief  came  by  a  profuse  hemor- 
rhage from  the  bowels,  and  recovery  occurred. 

A  very  excellent  paper  on  the  important  subject  of  albuminuria 
in  typhoid  fever  has  been  published  by  Hewetson,  in  which  he 

1  University  Medical  Magazine,  May,  1896. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.         105 

has  exhausted  the  literature.  He  quotes  Guiniet  as  having  met 
with  albuminuria  in  children  21  times  in  45  cases,  and  Mason  as 
having  met  with  it  in  60  out  of  676  cases,  of  which  45  recovered 
and  15  died.  At  the  Johns  Hopkins  Hospital  Hewetson  found 
it  in  164  out  of  229  cases,  but  tube  casts  were  found  in  only  103 
of  these.  He  also  found  that  the  period  in  which  albumin  ap- 
peared in  the  urine,  so  far  as  he  could  tell,  was  in  the  first  week 
in  6(5  per  cent,  of  the  cases  ;  in  the  second  week  in  75  per  cent.  ; 
in  the  third  week  in  41.6  per  cent.  ;  while  in  the  fourth  week  it 
occurred  in  35  per  cent.  A  very  interesting  thing  in  this  connec- 
tion is  the  fact  that  in  none  of  these  cases  were  there  any  objective 
signs  of  renal  disease,  any  uraemia,  or  oedema. 

Hanford1  has  also  shown  that  albuminuria  may  occur  in  typhoid 
fever  without  possessing  any  grave  prognostic  import,  but  the 
quantity  of  the  albumin  is  in  direct  ratio,  as  a  rule,  to  the  gravity 
of  the  case.  Among  patients  with  large  amounts  of  albumin  the 
mortality  is  usually  very  high. 

Albuminuria  occurred  in  31  per  cent,  of  190  cases  in  Nurem- 
berg, according  to  Zinn,2  and  epithelium  and  hyaline  casts  in  21 
per  cent. 

The  urine  in  typhoid  fever  is  nearly  always  decreased  in  amount 
in  the  acute  stage,  and  is  usually  darker  in  hue  than  normal,  con- 
taining a  high  percentage  of  solids.  Small  amounts  of  albumin 
may  be  in  it  without  indicating  nephritis,  but  if  casts  are  present 
much  albumin  is  usually  found,  and  the  diagnosis  of  nephritis  is 
justified.  About  20  per  cent,  of  all  cases  of  this  fever  show 
albuminuria  at  times,  but  even  if  mild  nephritis  develops  the 
prognosis  is  not,  as  a  rule,  grave.  Thus  in  the  Johns  Hopkins 
Hospital  albuminuria  occurred  in  164  out  of  229  eases,  and  tube 
casts  in  103;  altogether  21  out  of  these  229  eases  had  definite 
nephritis,  and  10  had  red  cells  in  the  urine  ;  2  suffered  from 
hemorrhagic  nephritis,  but  only  5  of  these  cases  died,  and  nunc 
of  them  from  the  renal  difficulty. 


1  London  Lancet,  April  28,  1889. 

2  Munchener  Medicinische  Wochenschrift,  February  14,  1899. 


106     COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER. 

Rostoski1  found  albumin  present  in  the  urine  205  times  in  346 
cases,  or  in  59.2  per  cent.  In  37  of  these  205  cases  the  albumi- 
nuria was  marked  and  hyaline  and  epithelial  casts  were  found, 
proving  the  presence  of  an  infectious  nephritis. 

Rostoski2  reports  two  cases  of  renal  typhoid  fever  as  follows  : 

A  patient  was  admitted  with  severe  headache  and  bronchitis. 
The  urine  contained  blood,  albumin,  and  epithelial  casts.  A  few 
days  later  the  characteristic  rash  and  diarrhoea  appeared.  Widal's 
reaction  gave  a  positive  result.  In  this  case  the  nephritis  passed 
into  the  chronic  disease. 

A  woman,  aged  twenty-six  years,  was  admitted  with  urine  con- 
taining blood  and  albumin,  and  subsequently  epithelial  casts. 
About  three  weeks  after  the  commencement  of  the  disease  Widal's 
reaction  was  obtained,  and  two  days  later  typhoid  bacilli  were  cul- 
tivated from  the  urine.  Five  days  afterward  the  patient  had 
severe  abdominal  pain,  with  vomiting,  and  moderate  collapse.  On 
the  next  day  the  whole  of  the  abdomen  was  exquisitely  tender. 
A  little  later  an  impaired  percussion  note  was  made  out  over  the 
ileo-csecal  region,  due,  as  it  was  thought,  to  a  localized  serous  peri- 
tonitis. The  patient  gradually  improved,  and  subsequently  made 
a  good  recovery.  The  case  was  very  obscure  at  first.  The  pres- 
ence of  an  acute  nephritis  was  only  recognized  thirteen  days  after 
the  onset  of  the  disease.  The  diagnosis  from  tuberculosis,  malig- 
nant endocarditis,  and  sepsis  was  very  difficult.  It  was  only  when 
Widal's  reaction  was  found  in  the  fourth  week  of  the  disease  that 
the  nature  of  the  case  became  obvious.  The  temperature  was  not 
characteristic,  but  the  spleen  was  enlarged.  The  signs  of  perito- 
nitis appeared  about  the  fiftieth  day,  shortly  after  the  administra- 
tion of  a  clyster ;  previously  there  had  been  no  intestinal  symp- 
toms.   The  patient  also  recovered  from  this  complication.    Rostoski 

1  Miinchener  Medicinische  Wochenschrift,  February  14,  1899.  This  is  the  most 
recent  paper  on  this  topic,  and  contains  references  to  the  literature  of  the  subject. 
The  title  of  the  paper  "Zur  Kenntniss  die  Typhus  Eenalis,"  refers  to  nephritis 
complicating  typhoid  fever,  and  not  that  of  the  form  of  onset  called  "nephro- 
typhus." 

2  These  cases  are  also  to  be  found  in  an  abstract  in  the  British  Medical  Journal 
of  April,  1899. 


WELL-JDEVELOPED  STAGE  OF  THE  DISEASE.  107 

expresses  the  opinion  that  in  every  case  of  nephritis  which  might 
be  classed  as  idiopathic,  but  which  has  a  high  temperature,  the 
urine  should  be  examined  for  typhoid  bacilli,  and  the  blood  tested 
for  Widal's  reaction. 

In  147  cases  admitted  to  the  German  Hospital  of  Philadelphia1 
in  1898  from  the  United  States  Army,  albuminuria  was  present 
in  57.1  per  cent.,  and  true  nephritis  in  25.2  per  cent. 

Late  in  the  disease  or  in  convalescence  a  transient  nephritis 
may  develop,  associated  with  pretibial  oedema. 

Aside  from  diffuse  nephritis  due  to  enteric  fever  we  find  that  the 
kidneys  may  be  the  seat  of  suppurative  processes,  developing,  as  a 
rule,  in  the  form  of  multiple  or  miliary  abscesses.  These  abscesses 
are  due  usually  to  infection  of  the  organ  by  the  ordinary  pyogenic 
cocci  and  rarely  to  infection  by  the  bacillus  of  Eberth.  The 
latter  condition  has,  however,  been  recorded  by  Flexner,  who  has 
studied  two  cases  of  focal  abscesses  in  the  kidney,  and  found  by 
careful  differentiation  that  this  bacillus  was  the  sole  cause  of  the 
lesion.  The  urine  in  these  cases  was  albuminous  and  contained 
blood-cells,  and  at  times  casts  covered  with  leucocytes.  There  are 
few  clinical  symptoms  which  can  be  used  to  diagnosticate  such 
lesions  other  than  those  shown  by  the  urine. 

Pyuria  arises  in  typhoid  fever  either  from  the  kidneys  (very 
rarely)  or  from  the  bladder.  It  varies  in  severity  from  the  pres- 
ence of  a  few  pus  cells,  which  are  found  with  difficulty  by  the 
microscope,  to  marked  pyuria  with  quantities  of  pus.  The  best 
study  of  this  subject  is  probably  that  of  Blumer.2  He  found  no 
less  than  16  cases  in  60  typhoid  fever  patients,  or  nearly  17  per 
cent.  In  some  the  pus  was  found  present  when  the  patient  came 
under  observation ;  in  4  cases  it  appeared  between  the  tenth  and 
fifteenth  day  ;  in  3  between  the  twenty-second  and  twenty-eighth 
day,  and  in  1  on  the  forty-second  day.  Its  duration  varied  from 
a  few  days  to  three  months.  In  nearly  all  his  cases  the  pus  was 
present  in  full  amount.  In  some  it  gradually  increased  ;  in  others 
it  came  in  large  amount  at  once.      The  organisms  found   in   the 

1  Philadelphia  Medical  Journal,  February  25,  1899. 

2  Johns  Hopkins  Hospital  Reports,  1895,  vol.  v. 


108     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

urine  were  the  colon  bacillus,  the  typhoid  bacillus,  staphylococcus 
albus,  and  an  unidentified  coccus.  The  colon  bacillus  was  found 
in  seven  cases,  the  typhoid  bacillus  twice,  and  the  staphylococcus 
once.  These  observations  are  important,  because  it  has  been  said 
by  Karlinski,  of  Krakow,  that  he  has  found  the  Eberth  bacillus  in 
no  less  than  50  per  cent,  of  all  cases.  In  all  probability  the  dif- 
ferentiation between  the  colon  bacillus  and  that  of  the  typhoid  was 
not  properly  carried  out. 

No  case  of  pyelitis  due  to  the  bacillus  of  Eberth  alone  has  as 
yet  been  reported,  which  is  interesting  in  view  of  the  well-known 
fact  that  this  bacillus  has  frequently  been  found  in  the  kidney 
after  death,  and  is  always  found  in  the  renal  lyniphoniata  of  this 
disease.  Konjajeff1  asserts  that  the  discovery  of  this  bacillus  in 
the  urine  indicates  the  development  of  these  formations  in  the 
kidney ;  but  this  is  improbable,  since  post-typhoidal  pyelitis,  not 
due  to  this  organism,  of  a  membranous  type  may  develop  and  be 
associated  with  a  membranous  cystitis. 

Richardson  has  recently  shown2  that  typhoid  bacilli  were  pres- 
ent in  the  urine  of  nine  out  of  twenty -eight  case&of  typhoid  fever  ; 
that  they  were  always  in  large  numbers  and  in  practically  pure 
cultures,  and  that  they  appear  in  the  later  stages  of  the  disease 
and  persist  in  most  cases  far  into  convalescence.  Their  presence 
is  nearly  always  associated  with  albuminuria  and  casts. 

In  a  still  later  report  Richardson3  reports  sixty-six  further 
cases,  of  which  fourteen  showed  the  presence  of  bacilli  in  the 
urine. 

Petruschky4  has  estimated  that  in  one  case  a  single  cubic  centi- 
metre of  urine  contained  170,000,000  typhoid  bacilli. 

Horton  Smith3  examined  the  urine  of  seven  typhoid  patients, 
with  three  positive  results,  and  he  remarks  that  the  micro-organisms 
may  be  so  numerous  as  to  cause  distinct  turbidity  of  the  urine. 

1  Central blatt  fur  Bakteriologie,  1889. 

2  Journal  of  Experimental  Medicine,  1898,  vol.  iii. 

3  Journal  of  Experimental  Medicine,  1899,  vol.  iv. 

4  Centralblatt  fur  Bakteriologie,  1898,  xxiii. 

5  Transactions  of  Medical  aud  Surgical  Society,  London,  1897. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  109 

Petruschky1  lias  pointed  out  that  the  bacillus  of  typhoid  is  often 
found  in  the  urine  some  weeks  after  the  temperature  is  normal. 

To  sum  up  the  evidence  from  a  clinical  point  of  view,  we  find 
that  pyuria  in  typhoid  fever  is  not  a  grave  sign,  hut  that  if  the 
specific  bacillus  is  found  in  the  uriue  the  patient  must  he  kept  under 
observation  till  it  disappears,  since  it  may  lead  to  serious  mischief. 

Pyonephrosis  has  been  recorded  by  Kernel.2  The  patient,  who 
had  previous  to  typhoid  fever  suffered  from  intermittent  hydrone- 
phrosis, developed  a  fluctuating  abdominal  tumor,  which  proved 
to  be  a  pyonephrosis  containing  a  pure  culture  of  the  bacillus  of 
Eberth. 

A  case  of  typhoid  cystitis  has  been  recorded  by  Houston.4  A 
woman,  aged  thirty-five  years,  had  suffered  from  cystitis  for  a 
long  period  of  time  ;  the  urine  was  strongly  acid,  turbid,  contained 
a  small  quantity  of  albumin  as  well  as  squamous  epithelium,  leu- 
cocytes,  and  some  bacteria.  A  bacillus  with  all  the  character- 
istics of  that  of  typhoid  was  cultivated,  and  her  blood  gave  a 
marked  typhoid  reaction  of  1.01.  A  second  examination  of  her 
urine  produced  similar  results  ;  although  the  patient  was  kept  in 
the  hospital  for  six  weeks,  there  were  no  other  typhoid  symptoms 
and  no  febrile  movement. 

In  all  probability  this  is  a  case  in  which  the  disease  had  been 
so  mild  at  some  previous  time  as  not  to  attract  attention,  but  the 
bladder-infection  had  persisted. 

Profuse  urinary  flow  is  sometimes  seen  in  the  latter  part  of 
defervescence  and  in  convalescence.  It  may  amount  to  ninety 
ounces  in  twenty-four  hours  for  many  days.  This  has  usually  no 
great  significance.  Hutchinson3  has  reported  a  case  of  diabetes 
mellitus  following  typhoid  fever. 

The  Alimentary  Canal  in  the  Developed  Stage.  Refer- 
ence has  already  been  made  to  pharyngeal  typhoid  lesions  in 
the  stage  of  onset.     A.  more  or  less  severe  inflammation  of  the 

1  Centralblatt  fur  Bakk'riologie,  1892,  xiv. 

2  Gazette  des  Hopitaux,  1897,  No.  10. 

3  Transactions  of  Association  of  American  Physicians,  1888,  vol.  iii. 

4  British  Medical  Journal,  January  14,  1S98. 


110     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER 

pharynx  is  to  be  found  in  nearly  all  severe  cases  of  typhoid  fever 
if  it  is  sought  for,  and  it  is  sometimes  sufficiently  marked  to  cause 
the  patient  to  complain  of  his  throat.  As  a  rule,  the  lesions 
consist  in  congestion  of  the  mucous  membrane  with  swelling  of 
the  glands  in  this  part  of  a  character  similar  to  that  met  with  in 
other  parts  of  the  alimentary  canal.  Pharyngeal  symptoms  may 
develop  in  convalescence  (which  see) ;  sometimes  membranous 
pharyngitis  coming  on  in  the  third  week  may  cause  death,  and 
Taupin1  records  a  case  in  which  it  asserted  itself  in  a  case  of 
typhoid  fever  complicated  with  measles. 

Gerloczy,2  a  physician  of  Budapest,  has  recorded  a  case  of  a 
girl  of  fourteen  years,  who  suffered  from  typical  typhoid  fever 
with  swelling  of  the  submaxillary  glands  and  the  development  of 
a  membrane  in  the  pharynx.  The  case  had  pulmonary  oedema, 
and  membranous  pharyngitis,  laryngitis,  and  bronchitis. 

Xot  only  are  inflammatory  changes  found  in  the  pharynx  in 
this  stage  of  typhoid  fever  but  also  in  the  oesophagus,  where,  of 
course,  they  are  apt  to  be  more  moderate  than  in  the  pharynx 
because  of  the  lack  of  lymphoid  tissue.  Usually  swelling  of  the 
glands  in  the  mucous  membrane  is  to  be  found  on  inspection.  As 
the  disease  progresses  these  changes  may  become  ulcerative  and 
severe.  Louis  and  Jenner  have  seen  cases  of  typhoid  ulceration 
of  the  oesophagus,  and  that  Roderer  and  "Wagner  have  seen  oeso- 
phagitis, as  have  also  Eichhorst  and  Reimer,  and  again,  Chauffer 
and  Cornil  have  described  a  condition  of  infiltration  of  the  mucous 
membrane  of  the  oesophagus  ^vith  a  formation  of  miliary  abscess. 
These  changes  will  be  found  discussed  in  the  chapter  dealing 
with  the  stage  of  convalescence. 

Symptoms  peculiar  to  the  stomach  are  comparatively  rarely 
met  with  in  typhoid  fever,  unless  dietetic  errors  have  caused 
them,  or  unless  by  the  excessive  use  of  drugs  or  stimulants  its 
functions  become  perverted.  On  the  other  hand,  when  gastric 
symptoms  arise,  either  as  the  result  of  the  causes  just  named,  or 

1  Journal  des  Connaissances  Med.  Chirurgicale,  1839. 

2  Deutsche  med.  Wochenschrift,  April  14,  1893. 


WELL-BE  VEL  OPED  ST  A  GE  OF  THE  DISEASE.  1 1  1 

because  of  some  unusual  feature  of  the  disease,  they  are  apt  to  be 
not  only  annoying  but  difficult  of  control.  Aside  from  moderate 
gastric  catarrh  due  to  the  fever  and  associated  with  a  condition  of 
insufficient  and  inefficient  gastric  juice,  which  is  peculiarly  marked 
in  these  cases,  the  unusual  symptoms  vary  from  hiccough,  which 
is  really  an  affection  of  the  diaphragm  produced  by  a  reflex  from 
the  stomach  in  many  cases,  to  vomiting,  and  from  discomfort  in 
the  epigastrium  to  severe  pain.  Disregarding  the  moderate  form 
of  hiccough  seen  so  often  accompanying  ordinary  indigestion,  we 
now  and  again  meet  with  cases  in  which  this  symptom  becomes 
not  only  annoying  but  exceedingly  dangerous,  in  that  it  causes 
rapid  exhaustion  and  failure  of  the  heart,  apparently  by  some 
associated  vagal  neurosis,  over  and  above  the  great  drain  upon  the 
patient's  strength.  Numerous  cases  are  on  record  in  which  this 
complication  lias  resulted  in  great  danger  or  even  in  death. 

Vomiting  in  typhoid  fever  may  be  an  unimportant  or  very 
grave  complication.  Often  it  occurs  because  of  indigestion  or 
irritability  of  the  stomach,  and  stops  as  soon  as  the  diet  is  altered 
or  the  quality  and  mode  of  using  stimulants  is  changed.  Its 
gravity  depends  largely  upon  its  persistency,  because  if  it  ensues 
on  taking  food  the  patient  speedily  dies  from  lack  of  nourishment, 
and  if  it  is  of  the  incessant  type,  resembling  the  status  epilepticus 
in  its  constancy  and  spasmodic  character,  the  patient  retching 
incessantly  whether  the  stomach  is  empty  or  not,  death  is  immi- 
nent because  of  direct  exhaustion.  Such  cases  are  not  common, 
but  when  they  occur  the  -prognosis  must  be  very  grave.  Some- 
times it  would  seem  as  if  the  vomiting  was  caused  by  a  neurosis 
or  by  poisoning  of  the  vomiting  centre  in  the  medulla. 

Still  more  rarely  in  typhoid  fever  the  vomiting  arises  from  ulcer 
of  the  stomach. 

Hemorrhage  from  the  stomach  is  very  rare  in  typhoid  fever  and 
is  almost  unknown.  Pepper  states  that  typical  typhoid  ulcers  may 
be  found  in  the  stomach,  and  from  them  it  is  possible  that  hemor- 
rhage may  occur.     Soltau  Penwick1  has  recorded  a  case  in  wliich 

1  Disorders  of  Digestion  in  Infancy  and  Childhood,  1897,  p.  380. 


112     COMPLICATIONS  AND  SEQUELjE  OF  TYPHOID  FEVER. 

typhoid  ulcers  nearly  perforated,  and  another  in  which  they  did 
perforate  but  general  peritonitis  was  prevented  by  the  liver  becom- 
ing adherent  to  the  wall  of  the  stomach.  Death  occurred  in  this 
case  from  profuse  hemorrhage  from  one  of  these  ulcers.  I  have 
only  met  with  one  case  in  which  hseruateroesis  took  place.  A 
woman  of  twenty-eight  years,  who  was  seized  with  a  very  severe 
attack  of  the  disease  died  at  the  end  of  the  first  week  immedi- 
ately after  vomiting  a  large  amount  of  blood  and  passing  a  great 

Fig.  15. 


Drawing  of  the  pyloric  end  of  the  stomach  in  a  case  of  enteric  fever,  a,  acute 
perforating  ulcers  with  clean  bases ;  b,  an  ulcer  with  adherent  slough.  ( W.  Sol- 
tau  Fexyvick.  ) 


quantity  by  the  bowel.  Ko  autopsy  was  held,  and  in  all  proba- 
bility the  blood  had  entered  the  stomach  from  the  small  bowel. 
The  following  cases  are  those  of  Fen  wick's  : 

"  Fig.  15  represents  a  drawing  of  a  stomach  taken  from  a  girl, 
eight  years  of  age,  who  succumbed  during  the  third  week  of 
enteric  fever.     Four  well-defined  ulcers  were  found  in  the  pyloric 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  113 

region,  one  of  which  presented  a  loosely  adherent  slough.  The 
edges  of  the  ulcers  were  sharply  defined  and  somewhat  under- 
mined, while  their  bases  were  situated  in  the  submucous  and 
muscular  coats  of  the  organ.  On  microscopic  examination  the 
lymphoid  tissue  of  the  stomach  was  found  to  be  enormously  in- 
creased, and  the  supposition  that  the  ulcers  originated  in  disease 
of  the  solitary  glands  was  confirmed  by  the  appearance  of  the 
smallest  one.  From  these  facts  it  would  appear  that  under  cer- 
tain circumstances  disease  of  the  solitary  gastric  glands  may  give 
rise  to  a  form  of  perforating  ulcer  of  the  stomach  which  closely 
resembles  the  idiopathic  type  of  the  disease. 

"A  girl,  thirteen  years  old,  was  admitted  into  the  hospital  with 
the  symptoms  of  typhoid  fever  of  eight  days'  duration.  Vomit- 
ing occurred  once  or  twice,  but  there  was  no  complaint  of  epigas- 
tric pain.  At  the  end  of  the  fourth  week  of  the  disease,  when 
the  temperature  had  begun  to  decline,  the  patient  was  suddenly 
seized  with  severe  hsematemesis,  after  which  she  became  uncon- 
scious and  died.  At  the  necropsy  the  anterior  wall  of  the  stomach 
was  found  to  be  adherent  to  the  under  surface  of  the  liver.  Scat- 
tered over  the  inner  surface  of  the  stomach  there  were  numerous 
sharply  defined  ulcers,  the  largest  of  which  was  about  the  size  of 
a  florin.  The  edges  were  thin  and  undermined  and  the  base  was 
formed  by  the  muscular  or  peritoneal  coat.  In  the  first  part  of 
the  duodenum  there  was  an  ulcer  of  a  similar  character,  while  the 
whole  of  the  intestine,  from  the  jejunum  to  the  rectum,  was  rid- 
dled with  typical  typhoid  ulcers." 

Osier  has  reported  the  following  cases  to  Keen  : 
"John  M.,  aged  forty  years,  was  admitted  August  21,  1890, 
with  a  history  of  illness  of  some  weeks'  duration.  The  chief 
symptoms  were  headache  and  fever.  The  blood  examination 
was  negative.  There  was  a  very  definite  rose-colored  eruption. 
The  temperature  was  never  high,  not  rising  above  103°.  On  the 
27th  he  vomited,  and  in  one  of  the  attacks  lie  brought  up  a  dark 
greenish-brown  fluid  containing  red  blood-corpuscles  in  a  condition 
of  disintegration,  and  a  clot  of  blood  about  3  by  2  em.  in  diameter. 
On  the  2i>th,  30th,  and  :51st   the  stools  were  very  dark  in  color, 


114     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

and  evidently  contained  blood,  and  several  times  he  vomited  very 
dark  material.    He  became  very  ansemic,  but  made  a  good  recovery. 

"Alberta  C,  colored,  aged  twenty  years,  admitted  June  14, 
1894.  This  patient  was  admitted  in  the  third  week  of  the 
disease.  On  that  afternoon  she  had  had  a  hemorrhage  from  the 
bowels.  She  was  bleeding  quite  freely  on  admission.  Between 
6  and  8  p.m.  she  had  five  large  stools  of  almost  pure  blood  with 
clots.  Throughout  the  following  day  she  was  extremely  feeble  ; 
temperature  was  normal ;  patient  was  delirious.  On  June  16th 
there  was  no  further  bleeding  from  the  bowels.  Toward  even- 
ing the  patient  was  delirious,  and  her  condition  was  very  bad. 
At  8.15  p.m.  she  vomited  100  c.c.  of  dark  bloody  fluid,  which 
contained  blood  coloring-matter  and  red  blood-corpuscles.  She 
sank,  and  died  that  evening. 

"Dr.  H.,  aged  twenty-two  years,  admitted  January  9,  1896. 
He  had  a  very  severe  attack,  with  persistent  fever,  which  re- 
sisted the  baths.  These,  though  given  from  the  outset,  did  not 
check  the  onset  of  quite  active  delirium.  On  January  25th, 
about  the  eighteenth  day  of  the  disease,  the  abdomen  was  a 
good  deal  distended ;  there  was  moderate  diarrhoea  and  less 
delirium.  He  seemed  to  be  doing  very  well.  He  had  had  no 
special  gastric  symptoms.  In  the  afternoon  he  quite  suddenly 
sprang  up  in  bed  and  vomited  a  quantity  of  dark  blood.  The 
amount  was  difficult  to  estimate,  as  it  went  all  over  the  bed 
linen.  Part  of  it  was  collected,  and  Dr.  Parsons  estimated  the 
amount  to  be  about  200  c.c.  It  contained  much  debris  and  red 
blood-corpuscles.  The  staining  on  the  sheets  was  quite  red.  On 
the  26th  the  temperature  was  between  103°  and  104°,  and  in  the 
afternoon  at  3.05  he  vomited  between  200  and  300  c.c.  of  almost 
pure,  bright-red  blood.  The  pulse  became  more  rapid,  but  these 
two  hemorrhages  did  not  appear  to  have  any  injurious  influence. 
His  temperature  gradually  fell  and  was  normal  on  the  31st.  He 
made  an  uninterrupted  recovery  after  a  most  severe  attack." 

Weiss1  records  a  case  of  a  soldier,  aged  twenty-two  years,  who 

1  Wiener  Med.  Presse,  1888. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  115 

died  from  profuse  gastric  hemorrhage  about  the  beginning  of  the 
third  week  of  typhoid  fever.  This  was  preceded  by  intestinal 
hemorrhage.  As  no  statement  is  made  as  to  whether  a  post- 
mortem confirmed  the  diagnosis,  the  case  is  to  be  considered  as  a 
doubtful  one. 

One  of  the  first  facts  which  attracts  our  attention  in  regard 
to  the  intestine  during  typhoid  fever  is  that  many  cases  of 
this  disease  are  recorded  in  which  at  the  autopsy  no  signs  of 
typhoid  fever  could  be  found  in  the  intestines.  Some  of  these 
have  not  been  as  carefully  studied  as  they  should  be,  but  others 
are  certainly  authentic.  Thus  Du  Cazal1  has  recorded  two  instances 
in  which  the  closest  inspection  failed  to  show  intestinal  lesions, 
yet  typhoid  bacilli,  which  responded  to  all  tests,  were  found  in 
the  spleen,  and  the  symptoms  of  the  disease  were  present  in  life. 
The  spleen,  mesenteric  glands,  and  kidneys  were  swollen  and  con- 
gested. Bacilli  of  typhoid  fever  were  obtained  not  only  from  an 
abscess  in  the  spleen,  but  also  from  vegetations  in  the  mitral 
valves  and  from  a  hemorrhagic  plaque  on  the  surface  of  the 
brain.  Banti2  and  Karlinski3  have  reported  similar  cases  not  so 
well  proven.     Karlinski's  cases  numbered  three. 

Nichols  and  Keenan1  have  reported  nine  cases  of  typhoid  fever 
without  intestinal  lesions.  So,  too,  Flexner  and  Harris5  have 
recorded  such  a  case,  and  Chiari  and  Kraus  met  with  seven  out 
of  nineteen  cases  in  five  months. 

Goodall"  reports  two  cases  of  enteric  fever,  fatal  during  the  third 
and  fifth  week  respectively,  in  which  there  was  no  intestinal 
ulceration.  The  first  patient  was  a  boy  of  thirteen  years,  who  had 
been  ill  a  fortnight  when  admitted  to  the  hospital ;  the  second 
was  a  man  of  thirty  years,  who  had  already  been  ill  ten  days. 
Both  of  them  showed  all  the  clinical  evidences  of  typhoid  fever, 

1  Bulletin  et  Soc.  Mem.  Med.  des  Hop.,  1893,  p.  248,  and  Le  Bulletin  M.'di- 
cal,  April  16,  1894. 

2  Archiv.  Italiennes  de  Biol.,  December,  1887. 

3  Wiener  Med.  Wochenschrift,  1891,  pp.  470and5U,  and  1&97,  vol.  ii.  p.  1850. 
*  Montreal  Medical  Journal,  1898,  xxvii.  p.  9. 

5  Johns  Hopkins  Hospital  Bulletin    1S97,  viii.  p.  2">9. 

6  Clinical  Society's  Transactions,  vol.  xx.w,  1897. 


116     COMPLICATIONS  AND  SEQUELM  OF  TYPHOID  FEVER. 

and  in  each  there  was  a  swelling  of  Peyer's  patches  without  ulcer- 
ation. Similarly  Fagge1  records  the  case  of  a  man  of  thirty-three 
years,  who  had  typhoid  fever,  and  whose  only  lesion  in  the  intes- 
tine consisted  of  one  ill-defined  purplish-red  patch  about  the  size 
of  a  shilling,  situated  a  foot  above  the  valve  and  a  little  higher 
up ;  another  patch  with  a  brush  surface,  which  was  visible  only 
when  it  was  examined  under  water.  So,  too,  in  November,  1880, 
Moore  showed  before  the  Pathological  Society  of  Dublin  a  case  of 
enteric  fever  in  which  there  was  no  disease  of  the  glands  of  the 
ileum,  while  the  spleen  was  extremely  large,  soft,  and  friable,  and 
Peyer's  patches  were  noted  appearing  less  distinct  than  usual, 
though  with  no  hypersemia,  and  did  not  present  the  shaven- 
beard  appearance.  Sydney  Phillips  has  reported  to  the  Clin- 
ical Society,  1891,  two  cases,  fatal  after  the  third  week,  with  no 
ulceration.  Goodall  points  out  that  out  of  sixty-three  autopsies 
he  has  held  in  cases  of  enteric  fever  at  the  Eastern  Hospital  he 
has  met  with  absence  of  ulceration  in  five  cases ;  in  two  of  these 
death  took  place  early,  on  the  eighth  and  tenth  days ;  in  two 
others,  as  the  result  of  some  complication,  on  the  thirty-second  and 
seventy -third  days. 

Other  cases  have  been  recorded  by  Beatty,2  Church,  and  Coup- 
land. 

Again,  Hodenpyle,3  of  New  York,  has  contributed  a  paper  upon 
this  subject,  reporting  a  case  of  undoubted  typhoid  fever  in  which 
the  intestinal  lesions  were  absent.  Brunschwig4  has  also  recorded 
a  case  of  this  kind,  and  Hoeffel5  has  done  likewise,  there  being  in 
his  case  but  slight  swelling  and  reddening  of  a  few  Peyer's 
patches.  Schultz  claimed  to  have  met  with  twenty-one  cases  out 
of  300  autopsies  of  this  disease  without  the  characteristic  ulcers  in 
the  ileum  ;  but  there  is  doubt  as  to  the  correctness  of  his  statement. 

1  Pathological  Society's  Transactions  for  1876. 

2  British  Medical  Journal,  June  16,  1897,  p.  148. 

3  British  Medical  Journal,  December  25,  1897. 

i  "Is  the  Lesion  of  Peyer's  Patches  a  Constant  Symptom  of  Typhoid  Fever?" 
Strasburg  Thesis  for  1870. 
5  Gazette  Medical  e  de  Strassburg,  1871,  No.  14,  p.  167. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  117 

Since  the  above  remarks  ami  quotations  were  put  in  type  a 
paper  upon  this  subject  has  been  published  by  J.  H.  Bryant.1  In 
it  he  reports  the  case  of  a  child  of  twenty-one  months,  who  died 
of  typhoid  fever  at  the  end  of  the  third  week,  and  whose  blood 
before  death  gave  the1  Widal  test.  The  autopsy  showed  that  the 
heart  weighed  one  and  one-half  ounces,  and  appeared  to  be  nor- 
mal. The  arteries,  mouth,  pharynx,  (esophagus,  and  stomach  were 
normal  in  appearance.  The  ileum  also  appeared  to  be  normal. 
There  was  no  ulceration,  and  the  Peyer's  patches  were  not  swollen 
or  discolored.  Nowhere  in  the  intestine  could  any  sign  of  recent 
typhoid  ulceration  be  found,  and  there  was  not  any  appearance 
suggesting  a  healing  or  healed  typhoid  ulcer.  The  peritoneum 
was  normal.  The  liver  weighed  sixteen  ounces,  and  had  a  normal 
appearance.  The  gall-bladder  and  pancreas  were  normal.  The 
mesenteric  glands  were  much  enlarged,  and  felt  very  soft ;  on  sec- 
tion they  presented  a  pinkish-gray  color,  and  appeared  to  be  in  a 
condition  of  acute  inflammation  ;  there  was  no  sign  of  suppuration 
or  caseation  in  any  of  them.  The  suprarenal  capsules  were  nor- 
mal. The  kidneys  weighed  three  ounces  ;  they  were  pale.  The 
spleen  wTas  a  little  enlarged. 

That  the  case  was  one  of  true  typhoid  fever  is  proved  by  the 
results  of  careful  bacteriological  study  of  the  tissues.  As  Bryant 
well  says  : 

"  Nothing  unusual  was  anticipated  before  the  necropsy  took 
place.  It  was  expected  that  the  usual  typical  ulceration  of  the 
Peyer's  patches  of  the  lower  part  of  the  ileum  would  be  found, 
and  great  surprise  was  expressed  when  no  swelling,  discoloration, 
ulceration,  or  other  abnormalities  whatsoever  could  be  detected  in 
the  Peyer's  patches,  solitary  glands,  or  mucous  membrane  of  any 
part  of  the  intestine.  I  thought  at  first  an  erroneous  diagnosis 
had  been  made,  and  suggested  that  the  symptoms  might  have 
been  accounted  for  by  the  broncho-pneumonia  which  was  found, 
although  the  character  of  the  pyrexia  was  against  this  view.  After 
finding  the  enlarged  mesenteric  glands,  I  suggested  that,  after  all,  it 

1  British  Medical  Journal,  April  1,  1899. 


118     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

was  most  probably  an  anomalous  case  of  typhoid  fever  without  any 
lesion  of  the  intestinal  mucous  membrane.  Cultures  from  the 
enlarged  mesenteric  glands  yielded  an  almost  pure  culture  of  the 
bacillus  typhi  abdominalis.  The  slight  clotting  of  the  milk  inocu- 
lated from  the  first  broth  culture  taken  directly  from  the  glands 
was  probably  due  to  a  slight  contamination  with  the  bacillus  coli 
communis.  It  will  be  noticed  that  coagulation  did  not  take  place 
until  after  forty-eight  hours,  and  then  it  was  only  slight.  I  could 
not  find  any  colonies  of  the  bacillus  coli  communis  on  the  gelatin 
plates,  although  I  looked  and  carefully  examined  for  them,  so 
that  if  present  originally  the  number  must  have  been  insignificant. 
The  bacillus  obtained  from  the  gelatin  plates  gave  the  character- 
istic positive  and  negative  reactions  of  the  bacillus  typhi  abdomi- 
nalis, namely,  did  not  produce  gas  in  any  media,  did  not  cause 
milk  to  clot,  did  not  produce  indol,  did  not  produce  acid,  did  not 
liquefy  gelatin,  and  further,  these  bacilli  obtained  from  a  recent 
culture  and  treated  with  both  50  per  cent,  and  5  per  cent,  serum 
from  a  typhoid  patient,  and  also  from  an  immunized  rabbit, 
clumped  together  in  a  manner  characteristic  of  the  bacillus  typhi 
abdominalis." 

Byrant  also  quotes  the  following  cases  not  mentioned  in  my  text 
before  I  read  his  article  : 

Time,1  in  1889,  described  a  case  in  which  during  life  the  fever 
was  of  a  recurrent  type,  and  the  spleen  was  found  to  be  consider- 
ably enlarged.  At  the  necropsy  slight  swelling  only  of  Peyer's 
patches  was  found.  The  bacillus  typhi  abdominalis  is  stated  to 
have  been  obtained  from  the  spleen  and  kidneys,  but  is  not  suffi- 
ciently identified  as  such. 

Vaillard,2  in  1890,  reported  the  case  of  a  young  soldier  who 
died  after  an  illness  of  three  days'  duration.  The  chief  symp- 
toms were  headache,  epistaxis,  pyrexia,  constipation,  retraction  of 
the  neck,  and  coma.  At  the  necropsy  congestion  of  the  lungs 
and  meninges  was  found,  but  there  was  no  intestinal  lesion.     The 

1  Jahresbericht  iiber  die  Fortschritte  ( Baumgarten  )  1889,  196. 

2  La  Semaine  Medicale,  March,  1890,  p.  94. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  119 

bacillus  typhi  abdominalis  was  obtained  by  culture  from  the  spleen, 
lungs,  and  spinal  cord  ;  streptococci  were  also  obtained  from  the 
spleen  and  meninges. 

Guarnieri,1  in  1S!)2,  described  a  case  of  typhoid  fever  which 
during  life  presented  the  characteristic  symptoms  of  the  disease. 
No  intestinal  lesion,  however,  was  found  at  the  necropsy,  but  the 
bacillus  typhi  abdominalis  was  obtained  by  culture  from  the  biliary 
passages,  liver,  and  spleen. 

Vincent,2  in  1893  described  the  case  of  a  man,  aged  thirty-five 
years,  who  died  about  the  twelfth  day  after  the  onset  of  a  severe 
illness  characterized  by  pyrexia,  diarrhoea,  purpura,  and  coma. 
At  the  necropsy  the  Peyer's  patches  were  found  to  be  normal ;  the 
mucous  membrane  of  the  intestine,  however,  was  congested.  The 
spleen  weighed  230  grammes ;  the  mesenteric  glands  were  not 
enlarged  ;  bilateral  pulmonary  congestion  was  found.  The  bacil- 
lus typhi  abdominalis  and  streptococci  were  obtained  from  the 
spleen,  liver,  kidneys,  and  heart. 

Osier  mentions  a  case.  The  patient  was  a  man,  aged  sixty 
years,  who  was  admitted  into  the  hospital  under  his  care.  He  had 
been  ill  for  about  two  months,  and  on  admission  was  found  to  be 
suffering  from  shortness  of  breath,  and  presented  signs  of  pneu- 
monia affecting  the  lower  lobe  of  the  right  lung.  Death  took 
place  twenty -four  hours  after  admission.  A  diagnosis  of  senile 
pneumonia  was  made  during  life.  At  the  necropsy  the  lower  lobe 
of  the  right  lung  showed  fresh  pneumonia  passing  on  to  a  condi- 
tion of  gangrene.  There  was  no  intestinal  lesion.  The  organs 
were  submitted  to  a  bacteriological  examination  by  Flexner,  and 
pure  cultures  of  the  bacillus  typhi  abdominalis  were  obtained  from 
the  lungs  and  spleen. 

Mettenheimer3  records  an  epidemic  of  typhoid  fever  occurring 
in  the  army  in  which  in   twenty-one   cases  the   intestinal    lesions 


1  Rivista   Genorale   Italiana  di  Clinica  Medica,   1897;  Baumgarten's  Jahres- 
bericht,  1897,  234. 
-  Annates  de  l'lnstitut  Pasteur,  February,  1893. 
3  Jabresberichte  iiber  die  Gesammte  Med.,  1872,  Bd.  2,  p.  236. 


120     COMPLICATIONS  AND  SEQUEL M  OF  TYPHOID  FEVER. 

were  entirely  limited  to  the  colon.     Banti1  and  Karlinski2  have 
also  reported  cases  of  this  character. 

A  case  is  recorded  in  Cheadle's3  service  at  St.  Mary's  Hospital 
of  a  child  of  three  years  who  died  of  typhoid  fever,  and  at  the 
necropsy  no  ulceration  was  present  in  the  intestine  and  Peyer's 
patches  appeared  to  be  normal.  Beatty4  records  two  cases  with  a 
similar  condition  present. 

Diarrhoea  is  speedily  ceasing  to  be  a  fairly  constant  symptom  of 
the  disease.  As  a  matter  of  fact,  it  is  in  a  very  large  proportion  of 
cases  supplanted  by  constipation  from  the  beginning  to  the  end  of 
the  malady,  although  classical  works  nearly  all  regard  looseness  of 
the  bowels,  amounting  to  three  or  four  stools  a  day,  as  the  usual 
condition  in  average  attacks.  This  is  particularly  the  case  in  the 
typhoid  fever  of  children,  in  whom  constipation  occurs  even  more 
commonly  than  in  adults. 

Students  very  often  seem  to  have  the  idea  that  the  absence  of 
diarrhoea  in  a  given  case  is  an  important  point  against  the  diag- 
nosis of  typhoid  fever.  On  the  contrary,  it  is  so  often  absent  that 
its  absence  is  of  no  negative  value  whatever,  although  its  presence 
possesses  more  importance.  Certainly  constipation  is  much  the 
more  frequent  state  as  we  meet  the  disease  in  Philadelphia,  and 
as  Osier  well  points  out,  diarrhcea  occurs  in  Baltimore  in  not  more 
than  30  per  cent,  of  his  cases,  and  is  an  active  form  in  only  about 
12  per  cent.  So,  too,  we  find  that  in  CurschmannV  clinic  from 
1880  to  1892,  diarrhoea  was  met  with  in  only  25  per  cent,  of  the 
cases  (1626  cases).  Phillips  tells  us  that  of  200  consecutive 
cases  in  St.  Mary's  Hospital,  London,  diarrhoea  occurred  in 
115,  constipation  in  48,  but  in  many  of  these  cases  diarrhcea 
had  been  set  up  by  a  purge  given  before  the  diagnosis  was 
made,  so  that  his  experience  in  no  way  militates  against  the 
statistics  just  cited. 

1  La  Riforma  Medica,  1887,  p.  1448. 

2  Wiener  Med.  Wochen.,  1891,  pp.  470  and  511. 

3  The  Lancet,  July  31,  1897,  p.  254. 

4  British  Medical  Journal,  January  16,  1897. 
3  Deutsche  Archiv.  f.  klin.  Medicin,  1895. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  121 

In  the  Maidstone1  epidemic  50  per  cent  of  the  cases  were  con- 
stipated.     Murchison  found  it  in  93  out  of  100  cases. 

When  the  diarrhoea  is  excessive,  amounting  to  ten  and  twenty 
stools  a  day,  the  diet  has  usually  been  faulty  in  the  extreme,  or 
ulceration  of  the  large  bowel,  amounting  to  a  dysenteric  state,  is 
generally  present.  The  character  of  the  stools  is  usually,  in  the 
cases  with  moderate  diarrhoea,  quite  typical,  but  green  stools  in 
typhoid  fever  are  occasionally  met  with.  They  have  been  re- 
ferred to  by  Dreschfeld  in  Allbutt's  System  of  Medicine,  the  discol- 
oration being  seen  during  convalescence.  Quill2  has  recorded  a 
case  in  which  bright-green  material  was  vomited  on  the  eighth 
day,  and  later  the  patient  passed  bright-green  fluid  stools.  There 
was  great  pain  in  the  back.  Garrod,  Drysdale,  and  Kanthack3 
report  three  cases.  The  stools  resembled  chopped  parsley,  and 
the  liquid  portion  of  the  stools  when  filtered  off  contained  bili- 
verdin,  which  was  probably  responsible  for  the  discoloration  of 
the  excreta. 

The  next  point  to  be  considered  in  this  connection  is  whether 
diarrhoea  is  a  sign  of  mild  or  severe  infection.  The  consensus 
of  opinion  seems  to  be  that  diarrhoea  is  usually  more  active  in 
serious  cases.  Whether  this  is  an  instance  of  "  purging  as  an 
effort  at  elimination,"  a  favorite  theory  with  those  who  are  fond 
of  using  purgatives  and  so-called  intestinal  antiseptics,  with  the 
idea  that  by  so  doing  they  eliminate  poisons  and  prevent  their 
formation,  or  whether  it  is  a  manifestation  of  severe  ulceration 
of  the  bowel  with  an  associated  catarrh,  is  difficult  to  determine. 
Ord4  agrees  with  the  view  that  diarrhoea  is  usuallv  associated  with 
ulceration,  and  his  opinion  has  been  confirmed  by  the  autopsies  he 
has  seen.  Peabody  states  the  case  exactly  opposite  to  this  view. 
That  Ord's  view  is  not  correct  seems  proved  by  the  fact  that 
advanced  ulceration  is  often  found  in  cases  which  have  not  had 
diarrhoea  and  cases  of  marked   diarrhoea  are  seen  in  which  the 

1  Poole.     Guy's  Hospital  Reports,  1898.     Wrongly  labelled  on  cover,  1896. 

2  British  MedicalJournal,  October  22,  1898,  p.  1252. 

3  St.  Bartholomew's  Hospital  Reports,  vol.  xxxiii. 

*  Transactions  Association  of  American  Physicians,  1SSS,  vol.  iii. 


122     COMPLICATIONS  AND  SEQUELM  OF  TYPHOID  FEVER. 

autopsy  does  not  reveal  much  intestinal  ulceration.  In  Bryant's 
case,  already  quoted,  diarrhoea  was  active,  yet  no  intestinal  lesions 
were  found.  In  all  probability  diarrhoea  is  neither  indicative  of  a 
severe  nor  a  light  attack  in  many  cases,  although  if  it  be  violent 
the  exhaustion  produced  by  the  discharges  may  seriously  imperil 
the  patient's  chances  of  recovery.  This  view  is  strongly  advo- 
cated by  Sydney  Phillips,  who  regards  diarrhoea  as  a  symptom 
adding  danger  to  the  progress  of  the  typhoid,  as  he  believes  it 
prevents  absorption  of  nutriment  and  drains  the  body  of  fluid  ;  he  is 
therefore  distinctly  opposed  to  the  so-called  "  purgative  treatment." 
Closely  allied  to  this  question  of  diarrhoea  and  constipation  is 
that  of  the  gravity  of  tympanites,  a  condition  almost  always  pres- 
ent at  some  time  during  the  course  of  even  the  mildest  attacks, 
and,  as  a  rule,  less  frequently  present  in  cases  with  active  diarrhoea 
than  in  those  with  constipation,  although  a  great  accumulation  of 
gas  in  the  intestines  is  also  met  with  in  some  instances  in  which 
the  bowels  are  moving  quite  frequently.  As  a  rule,  such  pas- 
sages are  small  in  bulk  and  unsatisfactory  in  quantity,  and  are 
usually  quite  fetid.  The  gravity  of  tympanites  as  a  symptom 
depends  chiefly  upon  its  ability  to  do  harm,  and  this  harm  is  in 
direct  proportion  to  the  degree  of  its  interference  by  pressure  with 
the  functions  of  the  thoracic  and  abdominal  organs.  That  is  the 
strain  put,  by  the  distention,  upon  those  parts  of  the  bowel-wall 
which  are  weakened  by  ulceration  and  in  danger  of  perforation 
from  this  cause,  or  to  the  stretching  of  the  floor  of  an  ulcer, 
thereby  inducing  hemorrhage.  The  degree  of  tympanites  is  not 
always  a  definite  guide  as  to  the  damage  it  may  do.  It  may  be 
extreme  in  one  case  and  moderate  in  another,  and  yet  in  the  first 
instance  very  little  harm  seems  to  be  done  by  it,  while  in  the 
second  instance,  either  by  reason  of  cardiac  susceptibility  or  pecu- 
liar application  of  the  pressure,  the  injury  may  be  grave.  While, 
therefore,  the  degree  of  the  tympanites  is  in  direct  ratio  to  its 
evil  effects,  as  a  rule,  cases  are  continually  met  with  in  which 
it  is  excessive  and  yet  in  which  no  bad  results  ensue.  When 
the  tympanites  is  very  excessive  constipation  may  result  from 
paralytic    distention    of   the   gut,   and,   on   the    other    hand,   the 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  123 

paralysis  or  relaxation  of  the  bowel  may,  by  preventing  peri- 
stalsis, permit  the  accumulation  of  gas. 

Pain  in  the  abdomen  is  very  distinctly  a  symptom  of  the  early 
stages  of  the  disease,  and  in  many  cases  is  due  to  gas  produced  by 
fermentation.  The  pain  is  usually  wandering  and  is  not  con- 
stantly iu  one  spot,  and  if  it  becomes  fixed  it  probably  depends 
upon  a  localized  complication.  Pressure  upon  the  belly-wall  is 
apt  to  increase  the  pain.  It  is,  however,  a  noteworthy  fact  that 
later  on  in  the  disease,  when  tympanites  is  often  excessive  and 
the  bowel  greatly  distended,  there  is  apt  to  be  little  or  no  pain 
even  on  pressure,  perhaps  because  the  atony  of  the  muscular  coat 
of  the  bowel  prevents  griping,  and  the  tenderness  of  the  first  stage 
of  swelling  and  inflammation  is  supplanted  by  a  state  of  local  and 
general  nervous  torpor. 

Hemorrhages.  The  frequency  with  which  hemorrhages  occur 
varies  greatly  iu  different  epidemics,  independently  of  any  specific 
line  of  treatment  over  and  above  rest  in  bed.  Lack  of  such  rest 
at  any  stage  of  the  malady  certainly  predisposes  the  patient  to 
this  accident. 

In  861  cases  of  this  disease  without  the  cold  bath  in  Lieber- 
meister's  clinic  at  Basel,  hemorrhages  occurred  72  times,  or  8.4 
per  cent.  Griesinger  met  with  32  cases  in  600,  or  in  5.3  per 
cent. ;  and  Louis  found  them  in  5.9  per  cent.,  excluding  mild 
cases  ;  Berg,  in  1626  cases,  met  with  them  in  5.5  per  cent.  The 
younger  Wunderlich  has  recorded  98  cases  of  typhoid  fever  with- 
out the  bath,  with  hemorrhage  in  2  cases,  or  about  2  per  cent. 
Kraft1  found  in  the  study  of  intestinal  hemorrhage  in  typhoid 
fever  that  it  occurred  in  4.24  per  cent,  of  cases,  and,  curiously 
enough,  that  women  were  more  frequently  attacked  than  men, 
while  on  the  other  hand,  more  males  died  from  this  accident  than 
females.  He  does  not  think  that  the  prognosis  depends  directly 
upon  the  amount  of  blood  lost.  We  find,  therefore,  that  in  155!) 
cases  treated  without  the  cold  bath  there  were  99  hemorrhagic 
cases,  or  5.2  per  cent. 

1  Centralblatt  f.  die  med.  Wissenschaften,  1893,  p.  137. 


124     COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER. 

On  the  other  hand,  we  find  that  in  bathed  patents  Wunderlich, 
Jr.,  records  155  cases  with  16  hemorrhagic  patients,  or  10.3  per 
cent.  Ininiermann,  at  Basel,  records  146  cases  with  6  hemor- 
rhages, or  4.1  per  cent. ;  and  Liebermeister,  882  cases  with  45 
hemorrhages — 1183  cases,  or  6.8  per  cent. 

This  is  shown  best  by  the  following  table  : 


Without  Bath. 

Cases. 

Hemorrhages. 

Per  cent, 

Liebermeister    . 

.        S61 

72 

8.4 

Griesinger 

.       600 

32 

5.3 

Wunderlich,  Jr. 

98 

2 

2.0 

>r                Total 

I 

With 

.     1559 
Bath. 

106 

5.2 

Cases. 

Hemorrhages. 

Per  cent 

Liebermeister    . 

.        882 

55 

6.2 

Immermann 

.       146 

6 

4.1 

Wunderlich,  Jr. 

.       155 

16 

10.3 

Total 


1183 


77 


6.8 


To  these  may  be  added  :  In  America,  with  baths,  Wilson's  140 
cases  with  10  hemorrhages,  or  7  per  cent.;  Osier's  356  cases  with 
12  hemorrhages,  or  3.4  per  cent.1 

It  is  interesting  to  note  in  this  connection  that  Fitz  places  the 
general  frequency  at  5  per  cent,  and  Loomis  at  5  per  cent.  It  is, 
however,  only  fair  to  state  that  Goltdammer,  from  nearly  20,000 
cases,  concludes  that  the  bath  does  not  increase  hemorrhages. 
Brand  claims  that  they  are  less  frequent  in  the  bath  treatment,  as 
do  also  Tripier  and  Bouveret ;  but  Eoland  G.  Curtin  tells  us  that 
upon  investigation  he  found  that  since  the  cold-water  treatment 
has  been  instituted  the  number  of  hemorrhagic  cases  has  consider- 
ably increased,  according  to  the  hospital  records  that  furnish  the 
data,  and  in  addition  the  mortality  of  the  hemorrhagic  cases  is 
largely  increased,  viz.,  from  five  in  seventeen,  less  than  one-half, 
to  twenty-five  in  forty-three  cases,  or  over  one-half  ;  and,  further, 
on  inquiry  he  found  that  in  two  of  his  tabulated  cases  the  hemor- 


1  Onlv  299  were  bathed. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  125 

rhage  seemingly  took  place  while  the  patient  was  in  a  bath,  and 
in  one  ease  immediately  after  a  bath. 

An  important  point  in  this  connection  is  the  question  as  to  the 
real  danger  to  the  patient  from  hemorrhage.  In  this  opinions 
greatly  differ.  Thus  Fit/  tells  us  that  it  is  always  a  serious 
symptom,  but  rarely  fatal  in  private  life  ;  but  that  it  may  be  very 
disastrous  i-  shown  by  the  fact  that  Liebermeister  mentions  49 
deaths  due  to  this  cause  out  of  127  deaths;  Murchison,  53  deaths 
from  hemorrhage  out  of  100  deaths,  and  Homolle,  44  per  cent, 
in  498  deaths.  Osier  asserts  that  death  occurs  in  from  35  to  50 
per  cent,  of  hemorrhagic  cases.  Out  of  Griesiuger's  32  cases  10 
died,  7  of  these  within  four  days  of  the  hemorrhage.  Lieber- 
meister tells  us  that  among  his  own  cases,  38.6  per  cent,  died  when 
they  had  hemorrhage,  as  against  11  per  cent,  without  this  acci- 
dent, and  Tyson  tells  us  that  the  7  per  cent,  mortality  in  his  cases 
under  the  bath  treatment  was  due  entirely  to  hemorrhage  or  per- 
foration.    It  is  evident  that  Osier's  percentage  is  about  correct. 

On  the  other  hand,  it  has  been  noted  by  some  clinicians  that 
if  the  hemorrhages  are  not  sufficient  to  produce  profound  ex- 
haustion the  patient  often  does  better  after  their  occurrence  than 
before.  This  fact  was  at  one  time  insisted  upon  by  Dr.  Alfred 
Stille,  and  it  is  certainly  true  in  a  certain  proportion  of  cases. 

While,  as  a  general  rule,  the  dauger  is  in  direct  ratio  to  the 
quantity  of  blood  lost,  recovery  may  occur  even  after  enormous 
quantities  have  been  passed.  I  have  had  a  case  which  recovered 
in  which  no  less  than  four  pints  of  blood  were  lost  at  one  bleeding 
and  Phillips  and  Wakefield,  in  1882,  saw  a  patient  who  bled 
"two  chamberfuls  "  and  recovered. 

As  a  rule,  bleeding  from  the  bowel  in  typhoid  fever  arises  from 
ulceration  of  an  arterial  twig,  but  cases  do  occur  where  blood 
comes  from  a  vein  which  has  been  opened  by  ulceration.  Phillips 
has  recorded  such  an  instance. 

In  children  hemorrhages  from  the  bowel  are  more  rare  than  in 
adults  because  the  intestinal  lesions  are  not  so  marked,  as  a  rule. 

As  an  illustration  of  how  rarely  intestinal  hemorrhage  compli- 
cates typhoid   fever   in   children,  the  statement  of  Simon,  that   in 


126     COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER. 

twenty-one  years  of  practice  he  had  encountered  only  three  cases, 
is  of  interest. 

Hillier,  on  the  other  hand,  met  with  hemorrhage  in  4  out  of  30 
cases.  The  younger  the  child  the  less  is  the  liability  to  this 
accident. 

Peefoeattons.  Perforation  of  the  bowel  in  typhoid  fever 
bears  no  relation  to  the  severity  of  the  general  symptoms.  In 
many  cases  the  reporting  physician  states  that  the  attack  of  enteric 
fever  was  mild,  so  that  in  444  cases  collected  by  Fitz,  fully  200 
were  of  this  class.  In  fourteen  of  the  cases  the  patients  belonged 
to  the  class  known  as  "  walking  typhoid  "  cases.  Thus  Bennett1 
reports  the  case  of  a  man  who,  because  of  cardiac  dropsy,  was 
admitted  to  St.  Thomas'  Hospital.  He  was  purged  and  allowed 
to  eat  heartily.  Two  weeks  later  he  began  to  suffer  from  abdom- 
inal pain,  and  the  next  day  death  took  place  from  perforation  due 
to  typhoid  fever.  No  typhoid  symptoms  had  been  present.  Finn- 
cane2  reports  a  case  of  a  man  apparently  well  till  two  days  before 
death,  when  typhoid  perforations  occurred,  and  Kleinwachter3 
speaks  of  a  woman  who,  till  forty-eight  hours  before  her  death, 
was  at  business  and  who  was  suddenly  stricken  and  died  from  this 
cause. 

When  perforation  occurs  the  symptoms  are  apt  to  be  ushered 
in  by  agonizing  pain,  usually  felt  in  the  appendicular  region, 
which  may  be  severe  enough  to  rouse  the  patient  from  a  consider- 
able degree  of  coma.  The  belly  wall  speedily  becomes  tense  and 
tympanitic,  and  all  the  symptoms  of  a  general  diffuse  peritonitis 
speedily  ensue.  The  pain  may,  however,  not  be  persistent,  but 
pass  away  or  become  modified,  as  the  peritoneal  inflammation 
resulting  from  the  escape  of  fecal  matter  into  its  cavity  becomes 
more  and  more  septic.  The  pulse  becomes  rapid  and  running, 
and  collapse  may  speedily  assert  itself.  When  this  occurs  death 
speedily  comes  on,  the  patient  dying  in  a  few  hours,  or,  again,  he 
may  rally  and  survive  for  several  days.     Early  death  is,  how- 

1  Transactions  of  the  Pathological  Society,  London,  1866,  xvii.  121. 

2  Lancet,  1889,  ii.  793.  3  Wiener  Med.  Press,  1880,  xxi.  337. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  127 

ever,  the  more  common  result.  Thus  in  the  collection  of  thirty- 
four  cases  made  by  Fitz,1  of  Boston,  37.3  per  cent,  died  on  the 
first  day,  2!). 5  per  cent,  on  the  second,  and  83.4  per  cent,  in  the 
first  week.  During  the  second  week  nine  died,  in  the  third  week 
four  died,  and  two  other  cases  lived  thirty  and  thirty-eight  days 
respectively. 

If  collapse  does  not  ensue  the  rally  of  the  system  results  in 
a  rise  of  the  temperature  to  a  point  higher  than  before  the 
accident,  and  this  movement  is  often  accompanied  by  chills 
and  rigors.  Usually  by  the  second  or  third  day  the  peritoneal 
symptoms  become  more  and  more  marked,  the  condition  of 
the  patient  more  and  more  asthenic  and  depressed,  and  death 
results  by  the  fourth  day  from  a  general  peritonitis  with  toxaemia 
from  the  absorption  of  toxic  materials.  In  other  cases  the  onset 
of  the  perforation  is  insidious,  the  belly  before  the  perforation  may 
have  been  moderately  tympanitic,  but  now  becomes  intensely  hard 
and  swollen ;  the  pain,  which  in  some  cases  is  so  severe,  does  not 
develop,  but  the  great  fall  in  fever  followed  by  a  rise,  and  this 
again  by  rigors,  it  may  be,  give  evidence  of  the  grave  accident 
which  has  occurred.  The  pulse  becomes  increasingly  rapid  and 
running,  and  the  respirations  more  and  more  costal  and  less  and 
less  diaphragmatic,  until  the  patient  sinks  out  of  life,  without 
much,  if  any,  suffering,  in  much  the  same  manner  as  one  sees 
death  come  to  a  case  of  diffuse  septic  peritonitis  due  to  a  pus-tube 
or  an  old  appendicitis.  In  such  cases  the  perforation  is  usually 
very  small,  and  is  so  surrounded  by  adhesions  that  the  escape  of 
the  intestinal  contents  is  very  gradual  and  insidious,  infecting  the 
peritoneum  without  the  escaping  fluid  being  copious  enough  to 
produce  great  pain  or  infection.  This  possibility  of  perforation 
of  the  bowel  taking  place  insidiously  has  been  mentioned  by 
Sydney  Phillips,2  of  London.  To  use  his  words:  "  In  some  cases 
of  typhoid  fever  where  nerve-tone  is  already  lost  and  the  tym- 
panitic belly  is  soft  and  doughy,  perforation  and  after-peritonitis 

1  Transactions  of  the  Association  of  American  Physicians,  1891,  vol.  vi. 

2  British  Medical  Journal,  November  12,  1898. 


128     COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER. 

may  occur  almost  insidiously  with  little  pain,  collapse  signs  or 
alterations  in  temperature."  The  former  type  of  case  is  illus- 
trated by  the  case  of  a  medical  student  under  my  care,  who  while 
convalescing  from  a  very  mild  attack  of  the  disease,  and  who  had 
had  a  normal  temperature  for  several  days,  was  seized  at  midnight 
with  agonizing  pain  in  the  epigastrium,  so  severe  that  he  implored 
his  father  to  relieve  him  or  kill  him  in  order  to  stop  his  suffering. 
He  rapidly  passed  into  collapse,  and  died  in  eight  hours. 

The  insidious  form  is  shown  by  the  case  of  a  man  who  came 
under  my  care  in  the  third  week  of  the  disease,  much  exhausted  and 
emaciated,  but  without  very  high  fever  at  any  time.  At  the  end 
of  the  fourth  week  he  seemed  to  be  doing  very  well,  but  his  tem- 
perature, which  had  been  approaching  the  normal,  suddenly  rose 
to  104°,  accompanying  a  chill ;  his  belly  became  enormously  dis- 
tended, his  breathing  became  more  and  more  costal,  and  he  died 
at  the  end  of  the  third  day  from  exhaustion  and  asthenia,  with 
all  the  physical  signs  of  perforation. 

In  this  connection  it  is  interesting  to  note  that  a  sudden  fall  in 
temperature  is  not  a  symptom  necessary  to  the  diagnosis  of  intes- 
tinal perforation.  On  the  contrary,  there  are  many  cases  on 
record  in  which  a  rise  of  temperature  follows  this  accident. 
Thus  Lereboullet1  states  that  in  all  the  cases  of  perforation  he 
has  met  with  there  has  been  a  rise  not  a  fall,  and  he  quotes 
Lorain,  Brouardel,  and  Thoinot,  Griesinger,  Amould,  Lemoine 
and  Homolle  as  agreeing  with  him.  Monod2  also  reports  such  a 
case. 

Dieulafoy3  goes  so  far  as  to  assert  very  positively  that  peritonitis 
from  perforation  very  rarely  announces  itself  acutely,  with  sudden 
pain  and  marked  constitutional  symptoms.  On  the  other  hand,  its 
onset  is  generally  insidious.  The  sensibility  of  the  patient  is 
blunted,  the  peritoneal  infection  takes  place  slowly,  and  the  actual 
occurrence  of  perforation  may  escape  unnoticed. 

1  Academie  de  Medecine  de  Paris,  October  27  and  November  3,  1896.  Dis- 
cussion of  a  paper  entitled  "  De  l'lntervention  Cliirurgicale  dans  les  Peritonites 
de  la  Fievre  Typhoide,"  by  Dieulafoy. 

2  Ibid.  s  Ibid. 


WELL-DE VEL  OPED  STA  OE  OF  THE  DISEA SE.  129 

While  such  eases,  due  to  pin-hole  perforation,  may  occur,  they 
cannot  be  considered  common. 

Fitz  mentions  56  cases  in  which  the  onset  of  symptoms  of  per- 
foration were  severe;  15  in  which  it  was  gradual  or  latent,  and  5 
in  which  there  was  no  sign  of  perforation.  Such  cases  as  the  last 
named  are  recorded  by  Laboulbene,1  who  tells  us  that  there  was 
no  sign  of  perforation  save  a  chilliness  of  the  skin  and  a  slight 
fall  of  fever.  Bartlr  makes  a  similar  report,  and  Jenner3  reports 
a  case  which  left  bed  on  the  ninth  day  and  died  some  hours 
later  of  perforation,  there  being  no  complaint  of  pain  made. 

The  diagnosis  of  perforation  is  to  be  reached  by  the  following 
signs  in  addition  to  those  just  given.  Chief  and  foremost  among 
these  is  the  demonstration  of  gas  in  the  peritoneal  cavity,  so  that 
the  liver  is  pushed  away  from  the  abdominal  wall  in  such  a  man- 
ner that  the  ordinary  area  of  liver  dulness  largely  disappears. 
Percussion  of  the  right  hypochondrium  is,  therefore,  an  essential 
procedure  in  the  physical  diagnosis  of  these  cases.  The  only  fal- 
lacy underlying  this  test  is  the  possibility  of  a  portion  of  the 
colon,  when  greatly  distended  with  gas,  slipping  up  between  the 
liver  and  the  belly-wall,  and  thus  giving  resonance  ;  but  this  is  a 
rare  occurrence.  In  some  cases,  however,  as  already  intimated, 
the  symptoms  are  so  insidious,  the  death  so  gradual,  that  a  posi- 
tive diagnosis  is  not  positive,  and  cases  are  not  rarely  seen  in 
which  the  perforation  has  not  been  suspected  and  is  found  at  the 
autopsy. 

There  is  one  precaution  to  be  taken  in  cases  of  suspected  per- 
foration which  must  not  be  overlooked,  namely,  that  peritonitis 
may  develop  from  extension  of  the  inflammatory  process  in  the 
bowel  or  by  reason  of  the  migration  of  micro-organisms  through 
those  parts  of  the  bowel-wall  which  have  been  impaired  by  the 
ulcerative  process.  In  such  cases  the  pain,  swelling,  and  dia- 
phragmatic paralysis  may  all  be  present  without  being  due  to 
perforation,  and  so  closely  may  the  symptoms  of  perforation  be 

1  L'Union  Medicalo,  1S77.  xxiii.  389. 

2  Bulletin  de  la  Soc.  Anat.,  1884,  lix.  1  I  J. 

3  Medical  Times,  1850,  xxii.  298. 


130     COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER. 

aped  that  operation  has  been  performed,  with  the  discovery  that 
no  perforation  had  occurred ;  thus  in  a  case  under  the  care  of 
Herringhani,  nothing  was  found  at  the  section  and  the  patient 
recovered.  Perforation  may  be  simulated  by  rupture  of  the  peri- 
toneum over  a  swollen  mesenteric  gland. 

Other  causes  of  peritonitis  are  necrosis  of  the  mesenteric  glands, 
infarction  of  the  spleen,  or  the  development  of  abscess  in  an  ovary 
or  Fallopian  tube. 

Very  rarely  peritonitis  arises  from  cholangitis,  with  or  without 
gallstones,  and  Liebermeister  has  recorded  two  cases  in  which 
rupture  of  the  gall-bladder  with  escape  of  gallstones  into  the 
abdominal  cavity  took  place. 

What  the  ordinary  percentage  of  perforation  is  is  in  some  doubt, 
but  according  to  Murchison,1  it  is  in  the  neighborhood  of  3  per 
cent.  Schulz2  found  it  in  1.2  per  cent,  of  3686  cases  of  typhoid 
fever  in  Hamburg  in  1886  and  1887,  and  Liebermeister3  in  1.3 
per  cent,  in  2000  cases  in  Basel  in  1865  to  1872.  Berg,  in 
1626  cases,  met  with  it  in  2.2  per  cent.,  and  this  is  about  the  per- 
centage reached  by  Osier  in  cases  bathed  and  not  bathed. 

The  most  interesting  comparative  statement  as  to  the  fre- 
quency of  perforations  with  and  without  the  bath  is  that  made  by 
Mason. 

Thus  in  Boston  City  Hospital  the  percentage  of  perforations  in 
males  was  1.4,  and  in  females  1.3,  while  under  the  cold  bath  in 
Brisbane  it  was  3.6  per  cent,  in  males,  and  1.6  per  cent,  in  females. 
Liebermeister' s  statistics,  viz.,  that  there  were  twelve  cases  of  this 
accident  in  973  patients  before  the  bath  and  fourteen  in  1108 
after  it  was  introduced,  show  a  very  slight  difference. 

The  percentage  mortality  of  this  accident  is  very  high.  Of 
1721  autopsies  the  percentage  was  11.3,  according  to  Murchison. 
According  to  Holscher  it  was  found  in  2000  Munich  cases  114 
times  (5.7  per  cent.),  and  in  20  out  of  80  of  his  cases  which  ended 
in  death.    In  4680  cases  tabulated  by  different  writers,  Fitz  found 

1  Continued  Fevers  of  Great  Britain. 

2  Centralblatt  fur  Allegemeine  Path.  Anat.,  1891,  vol.  ii.  p.  289. 

3  Ziemsen's  Encyclopedia,  vol.  i. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE. 


131 


the  proportion  to  be  G.5S  per  cent.,  which  agrees  with  Holscher's 
statistics. 

Hoffmann  found  that  out  of  250  deaths  in  typhoid  fever  20 
were  due  to  perforation. 

Perforation  is  very  much  more  frequently  seen  in  men  than  in 
women.  Fitz  in  444  cases  found  71  per  cent,  in  men  and  29  per 
cent,  in  women.  In  21  cases  of  perforation  in  Basel,  15  were 
men  and  6  were  women,  and  Griesinger  in  14  cases  had  10  men 
and  4  women.  Murchison  also  found  in  24  cases  16  men  and  8 
women,  although  the  general  mortality  of  the  disease  among 
women  was  slightly  higher  than  among  men.  So,  too,  Bristowe, 
of  London,  met  with  this  accident  in  men  in  11  cases  out  of  15, 
and,  again,  Nacke1  collected  106  perforation  cases,  in  which  72 
were  in  men  and  34  were  in  women. 

The  period  of  the  disease  in  which  perforation  most  commonly 
takes  place  is  at  the  end  of  the  third  week  or  later.  Thus  in  twenty- 
two  cases  in  which  reliable  information  could  be  obtained  by  Lie- 
bermeister,  perforation  took  place  at  the  end  of  the  second  week 
twice,  during  the  latter  half  of  the  third  week,  six  times,  in  the 
fourth  week  twice,  in  the  fifth  week  six  times,  in  the  sixth  and 
seventh  weeks  twice  each,  and  later  than  this  twice.  Nacke  found 
it  84  times  out  of  185  cases  in  the  first  two  weeks,  and  99  later, 
62  out  of  117  cases  in  the  first  four  weeks,  and  55  later. 

More  accurate  statistics  are  those  of  Fitz,  who  in  193  cases 
obtained  facts  shown  in  the  following  table  : 

Date  of  Occurrence  in  Perforation. 


First 

Second 

Third 

Fourth 

Fiftli 

Sixth 

Seventh 


week 


Cases. 

Cases 

4 

Eighth    week  . 

.     3 

.32 

Ninth         "     . 

2 

48 

Tenth         "     . 

.     4 

42 

Eleventh    " 

.     3 

27 

Twelfth      "     . 

.     1 

21 

Sixteenth  "     . 

.     1 

5 

1  Ueber  die  Darmperforation  im  Typhus  Abdomlnalis.  Dissertation,  Wurzburg, 
1893. 


132     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

The  part  of  the  bowel  most  frequently  perforated  in  136  cases 
was  the  ileum  in  106  cases,  the  colon  in  12  cases,  and  the  vermi- 
form appendix  in  15  (Liebermeister).  Hoffmann1  tells  us  that 
out  of  20  cases  the  perforation  occurred  once  near  the  ileo-ceecal 
valve,  four  times  at  four  to  six  inches  above,  nine  times  at  eight 
to  twenty  inches,  twice  at  four  and  a  half  to  six  feet  above,  once 
at  ten  feet  above,  and  in  one  case  there  were  no  less  than  twenty- 
five  to  thirty  perforations  in  the  jejunum.  In  167  cases  collected 
by  Fitz,  the  perforation  occurred  in  the  ileum  in  136  instances 
(81.4  per  cent.),  in  the  large  intestine  in  20  (12.9  per  cent.),  in 
the  vermiform  appendix  in  5  cases,  in  Meckel's  diverticulum  in 
4,  and  in  the  jejunum  in  2.  In  19  cases  there  were  two  perfora- 
tions, in  3  five  perforations,  and  in  4  four.  Another  case  with 
multiple  orifices  has  been  cited. 

A  very  extraordinary  case  is  that  reported  by  Heagler.2  A 
woman  suffering  from  ventral  hernia  was  attacked  with  typhoid 
fever  and  perforation  of  the  ileum  occurred  in  the  hernial  sac. 
This  resulted  in  sloughing,  and  a  fecal  fistula  of  large  size  was 
formed.      Great  emaciation  ensued,  but  the  woman  recovered. 

An  interesting  case  of  typhoid  fever  with  secondary  lesions 
involving  the  left  half  of  the  scrotum  has  been  reported  by 
Spencer.3  The  patient  was  thought  to  be  suffering  from  influ- 
enza ;  and  had  suffered  from  a  hernia  in  the  left  inguinal  region 
for  nine  years.  When  first  seen  at  the  hospital  the  left  half  of  the 
scrotum  was  greatly  swollen  and  distended,  the  skin  being  oedema- 
tous ;  the  swollen  area  was  tympanitic  on  percussion,  opaque  to 
light,  and  fluctuated,  and  at  the  inguinal  region  there  was  a  firm 
mass  to  which  an  impulse  was  transmitted  on  coughing.  An 
incision  was  made  from  which  pus,  gas,  and  sloughing  omentum 
came  away.  The  patient  died  seventeen  days  later,  and  the  post- 
mortem revealed  the  fact  that  the  condition  of  the  scrotum  had 
been  due  to  the  perforation  of  a  typhoid  ulcer. 


Untersuch.  und  der  path.  anat.  Yerand.  d.  Organe  beim  Abd.  Typhus,  1869. 
Correspondenzblatt  fur  Schweizer  Aerzte,  1896,  Xo.  17. 
London  Lancet,  April  10,  1897. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE. 


133 


In  children  this  accident  is  very  much  more  rare  than  it  is  in 
adults.  J.  Lewis  Smith  states  that  it  is  met  with  only  once  in 
232  cases.  Wolberg  found  no  such  accident  in  277  cases  of  the 
disease  in  children  at  Warsaw.     Fitz  gives  the  following  table  : 


Adi:  at  which  Perforation  Occiks. 


1    to    10  years . 


10 
20 
30 
40 
50 
60 


20 
30 
40 
50 
60 
70 


7  =    3.6  per  cent. 

46  =  23.8 

77  =39.8 

45  =23.3 

14  =    7.2 

2  =    1.0 

1  =    0.5 


In  this  connection  the  account  given  by  Taupin1  of  intestinal 
perforation  in  children  is  of  great  interest.  He  tells  us  that  he 
saw  two  such  cases,  and  that  four  such  were  reported  in  1834,  1835, 
and  1838  by  Husson  and  Barrier.  Three  of  these  were  gravely 
ill,  and  when  perforation  occurred  they  passed  into  collapse  and 
died.  In  the  two  Taupin  saw  atrocious  pain  developed  in  the 
right  flank  and  collapse  ensued.  Death  occurred  in  thirty-six 
hours,  with  all  the  signs  of  peritonitis. 

To  one  unacquainted  with  the  subject  it  would  seem  that  there 
could  be  no  question  as  to  the  danger  of  death  from  this  lesion, 
yet  as  short  a  time  ago  as  1891  Reeves  stated  that  he  had  seen 
five  cases  presenting  all  the  signs  of  perforation,  and  yet  the 
patients  recovered.  At  the  same  meeting  Loomis  said  he  had 
never  seen  recovery  after  the  presence  of  unmistakable  signs  of 
perforation.  The  latter  view  was  that  held  by  most  of  the  earlier 
writers;  but  Buhl,  in  1857,  recorded  a  case  in  which  death  did 
not  succeed  perforation  for  forty-five  days,  and  then  as  the  result 
of  hemorrhage  from  a  mesenteric  artery.  The  autopsy  showed 
that  a  perforation  had  occurred,  but  had  been  closed.  Murchi- 
son  states  that  rare  cases  are  met  with  in  which  recovery  takes 
place.  At  the  present  time  it  is  a  well-recognized  fact  that  cases 
may  recover,  but  that,  as   Murchison   says,  they  arc  rare,  unless 


1  Journal  des  ( 'onnaissances  Med.  Chi.,  1839. 


134     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

surgical  aid  is   given  the   patient  very  soon  after  the   accident. 
(See  operative  interference.) 

Perforation  does  not  always  produce  death,  however,  because  it 
may  not  cause  anything  more  than  a  very  localized  abscess, 
owing  to  a  protective  peritonitis  which  walls  off  the  general 
cavity  from  infection.  Eisner1  reports  such  cases,  and  Pear- 
son2 records  a  case  in  which  during  relapse  an  ileocoecal  abscess 
formed,  the  pus  having  a  fecal  odor.  In  another  case3  a  man  had 
a  perityphilitis  on  the  twenty-eighth  day,  and  passed  two  ounces 
of  pus  by  the  rectum  on  the  fiftieth  day.  Keen  records  a  case  in 
which  an  abscess  formed  in  the  right  side,  which  opened  into  the 
ascending  colon,  and  finally  a  fecal  fistula  developed.  He  also 
records  a  case  sent  him  by  Dr.  Schuremen,  of  Tom's  River,  N.  J., 
of  an  abscess  which  opened  near  the  anus,  giving  vent  to  a  great 
deal  of  pus,  in  the  third  week  of  the  disease.  Later  another  open- 
ing formed.  Major1  records  a  case  in  which  collapse  occurred  on 
the  eighteenth  day  of  the  disease,  and  three  weeks  later  an  abscess 
burst  into  the  rectum,  and  the  patient  recovered. 

Low's5  cases  had  symptoms  of  perforation  in  the  third  week,  and 
peritonitis.  Later  an  abscess  burst  through  the  abdominal  wall, 
but  the  patient  recovered.  Again,  in  Lehman's  case  perforation 
occurred  at  the  end  of  the  third  week,  and  death  occurred  a  month 
later.  In  the  abdominal  pus  the  bacillus  of  Eberth  was  found. 
Schmidt6  has  recorded  a  case  of  pyopneumothorax  subphrenicus, 
from  which  three  quarts  of  pus  containing  a  pure  culture  of  the 
bacillus  of  Eberth  was  obtained. 

That  death  does  not  always  follow  rapidly  after  perforation  of 
the  bowel  in  typhoid  fever  is  also  proved  by  the  case  reported  by 
O'Carroll,7  in  which  perforation  of  the  intestine  occurred  on  the 
thirty-sixth  day,  and  the  patient  did  not  die  until  the  fifty-ninth 

1  Transactions  of  the  Medical  Society  of  the  State  of  New  York,  1892,  314. 

2  British  Medical  Journal,  1891,  i.  861. 

3  Adam.     Australian  Medical  Journal,  1887,  ix.  182. 

4  British  Medical  Journal,  1891,  i.  18.  5  Ibid.,  1881,  ii.  122. 

6  Deutsche  medicinische  Wochenschrift,  1896,  No.  32. 

7  British  Medical  Journal,  February  13,  1893. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  135 

day,  when  an  adhesive  peritonitis  was  found,  and  an  abscess 
which  had  been  walled  off  from  the  rest  of  the  peritoneum.  All 
of  the  intestinal  ulcers  except  the  one  which  had  perforated  had 
healed.     (See  also  operative  interference.) 

Without  doubt  many  of  the  cases  of  so-called  perforation  which 
have  been  reported  as  ending  favorably  have  been  cases  in  which 
there  Mas  no  perforation,  and  only  a  more  or  less  severe  localized 
peritonitis.  The  symptoms  of  this  condition  may  be  so  precisely 
those  of  perforation,  that  an  autopsy  or  exploratory  incision  may 
be  needed  to  differentiate  them,  and  peritonitis  may  arise  from  so 
many  intra-abdominal  lesions  that  its  presence  from  these  causes 
must  always  be  suspected. 

At  the  present  time  the  prognostic  and  therapeutic  view  of 
cases  of  perforation  are  well  expressed  by  the  following  quotations 
from  Gairdner,  Fitz,  Keen,  and  others  : 

Gairdner1  says  :  "  What,  then,  is  the  proportion  of  cases  which 
recover  without  surgical  interference  when  symptoms  of  general 
peritonitis  have  set  in  ? 

"  It  is  difficult  to  estimate  the  proportion  numerically,  but  such 
recoveries  are  certainly  exceedingly  rare.  Thus,  Todd  and  Jen- 
ner,2  in  a  long  life  of  large  experience,  saw  one  case  each  ;  Twee- 
die,  2  ;  Murchison  carefully  collected  six  cases,  but  only  two  were 
his  own. 

"A  fair  number  of  cases  may  be  found  in  medical  literature, 
reported  with  more  or  less  accuracy,  but  it  is  seldom  that  an  indi- 
vidual experience  includes  more  than  one  case,  while  many  of 
large  experience  have  seen  no  such  cases,  and  even  doubt  the  |  »<  ri- 
sibility of  recovery  after  perforation  of  the  intestine  freely  into 
the  peritoneal  cavity.  Now,  Murchison,  at  p.  524  of  the  second 
edition  of  his  work  on  continued  fevers,  states  that  in  ten  years, 
between  the  publication  of  the  first  and  second  edition  of  that 
work,  he  had  attended  '  more  than  two  thousand  cases'  of  enteric 
fever;  certainly  he  must  have  attended  even  more  before  the  pub- 

1  Glasgow  Medical  Journal,  vol.  xlvii.  p.  100. 

-  (  ollected  Essays  and  Lectures  on  Fevers,  pp.  311  and  484,  London,   Riving- 
ton,  Percival  &  Co.,  1893. 


136     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

lication  of  the  first  edition ;  so  that  his  personal  experience  up  to 
that  time  may  fairly  be  put  down  as  at  least  five  thousand.  In 
another  place  he  estimates  the  occurrence  of  perforation  of  the 
intestine  in  his  cases  at  a  fraction  over  3  per  cent.,  so  that  in  about 
150  of  these  cases  that  accident  must  have  occurred.  Two  only, 
as  we  have  seen,  recovered. 

"  If,  then,  the  number  of  unsuccessful  laparotomies  published 
be  trebled,  so  as  to  make  sure  of  including  those  unpublished, 
roughly  this  gives  fifty-four  unsuccessful  cases  and  five  successful 
cases. 

"  When  it  is  remembered  that  little  selection  has  been  made  in 
the  cases  operated  on  (Van  Hook's  dictum  is,  '  the  only  contrain- 
dication is  a  moribund  condition  of  the  patient '),  it  may  be  claimed 
that  the  '  prentice  hand '  of  surgery  has  considerably  improved  on 
the  very  best  treatment  by  other  means." 

Fitz  says  :  "  It  appears  from  this  statement  that  of  twenty- 
seven  cases  of  peritonitis  in  typhoid  fever,  whatever  may  have 
been  the  cause  of  the  former,  though  often  attributed  to  intestinal 
perforation,  three  recovered  after  operation,  seventeen  after  reso- 
lution, and  nine  after  the  spontaneous  discharge  of  the  pus.  The 
comparison  of  this  series  of  cases  with  those  showing  the  results 
of  early  laparotomy  for  symptoms  suggesting  typhoid  perforation, 
indicates  that  the  appropriate  treatment  for  this  complication 
would  be  delay  until  a  probable  encapsulated  exudation  proved 
unduly  slow  in  absorption.  An  immediate  or  early  laparotomy 
for  the  relief  of  the  peritonitis  seems  advisable  only  when  the 
patient's  condition  is  exceptionally  good.  Should  the  signs  of  the 
exudation  persist  for  a  week  or  more,  and  the  general  condition  of 
the  patient  permit  an  incision,  surgical  treatment  would  then  be 
strongly  advisable.  That  the  patient  may  live  for  weeks  after 
perforation  has  taken  place  is  illustrated  by  the  cases  of  Buhl  and 
Hoffmann  already  mentioned. 

"  In  brief,  immediate  laparotomy  for  the  relief  of  suspected 
intestinal  perforation  in  typhoid  fever,  is  only  advised  in  the 
milder  cases  of  this  disease.  In  all  others,  evidence  of  a  circum- 
scribed peritonitis  is  to  be  awaited,  and  may  be  expected  in  the 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  137 

course  of  a  few  days.  Surgical  relief  to  this  condition  should 
then  be  urged  as  soon  as  the  strength  of  the  patient  will  warrant." 

Keen  says  :  "  When  once  physicians  are  not  only  on  the  alert 
to  observe  the  symptoms  of  perforation,  but  when  the  knowl- 
edge that  perforation  of  the  bowel  can  be  remedied  by  surgical 
means,  has  permeated  the  profession,  so  that  the  instant  that  per- 
foration takes  place  the  surgeon  will  be  called  upon,  and,  if  the 
case  be  suitable,  will  operate,  we  shall  find  unquestionably  a  much 
larger  percentage  of  cures  than  have  thus  far  been  reported.  But 
even  at  present  we  have  a  reasonably  large  number  from  which 
to  draw  conclusions.  In  the  table  appended  to  this  chapter  Dr. 
Westcott  has  collected  eighty-three  well-authenticated  cases.  This 
gives,  as  a  general  result,  sixteen  recoveries,  or  19.36  per  cent,  of 
cures  and  80.64  per  cent,  of  deaths.  When  this  is  contrasted  with 
Murchison's  unchallenged  figures  of  90  to  95  per  cent,  of  deaths 
after  perforation  without  operation,  we  may  well  take  courage  for 
the  future." 

Since  Keen's  essay  was  published  additional  cases  have  been 
collected  by  Piatt,1  who  says  that  to  Keen's  list  he  is  able  to  add 
three  fatal  cases  published  before  1898,  but  of  which  he  knows 
nothing  more  than  the  result,  fourteen  cases  which  have  been 
recorded  subsequently,  and  his  own  three  cases.  The  additional 
cases  are  as  follows  :  J.  H.  Nicholas,2  two  cases  reported  to  the 
Royal  Academy  of  Medicine  in  Ireland,  1889,  both  fatal.  Podres 
and  Obalinski,  cited  by  Gasselewitsch  and  Wanach,3  one  fatal 
case.  Gasselewitsch,4  one  case  ;  operation  immediately  after  the 
onset  of  symptoms  of  general  peritonitis  ;  perforation  sutured  ; 
death  after  forty-three  hours.  J.  B.  Deaver,5  a  male,  aged 
twenty-seven  years  ;  perforation  during  the  second  week  ;  opera- 
tion within  twenty-four  hours ;  free  gas  in  the  abdomen ;  no 
attempt  made  to  localize  the  perforation  owing  to  great  distention 

1  London  Lancet,  February  25,  1899. 

2  The  Lancet,  August  3,  1889,  p.  211).  3  Loc.  <it. 

4  St.  Petersburger  Medicinische  Wbchenschrift,  L898,  No.  -  (Centralblatt  f. 
Chirurgie,  1898,  No.  L9). 

5  American  Journal  of  the  Medical  Sciences,  1898,  vol.  ex  v.  pp.   L89-192. 


138     COMPLICATIONS  AND  SEQUEL  JE  OF  TYPHOID  FEVER. 

of  intestines ;  irrigation  and  drainage ;  recovery ;  Widal's  reac- 
tion obtained.  H.  C.  Deaver  (reported  by  J-  B.  Deaver),1  a  male, 
aged  thirty-six  years ;  perforation  in  the  third  week ;  operation 
after  thirty-six  hours  ;  death.  Burrell  and  Bottoniley,2  two  cases, 
one  recovery  and  one  death.  Handford  and  Anderson  (Notting- 
ham),3 a  male,  aged  twenty-seven  years  ;  perforation  on  the  thirty- 
third  day  of  a  mild  attack ;  operation  after  twenty-two  and  a 
half  hours  ;  perforation  sutured  ;  peritoneum  cleaned  by  sponges  ; 
wound  closed  without  drainage ;  recovery.  Pickering  Pick  (re- 
ported by  Rolleston),4  a  male,  aged  twenty-one  years ;  typhoid 
perforation  of  the  appendix  ;  the  appendix  removed ;  death  on 
the  second  day.  A  case  mentioned  by  Dr.  Goodall  in  the  discus- 
sion upon  Mr.  Pick's  case  at  the  Clinical  Society  of  London :  A 
girl,  aged  eight  years  ;  perforation  during  relapse  ;  sutured  ;  death 
after  four  days.  J.  B.  Deaver,5  a  female,  aged  twenty-three  years  ; 
perforation  on  the  twenty-first  day ;  operation  fifteen  or  sixteen 
hours  afterward  ;  perforation  sutured  ;  death  after  two  and  a  half 
days.  Woodward,6  a  male,  aged  eighteen  years ;  perforation  at 
the  end  of  the  second  week ;  operation  after  nine  and  a  half 
hours  ;  perforation  sutured  ;  the  patient  recovered  from  the  oper- 
ation, but  died  nine  days  later  from  typhoid  fever.  At  the 
necropsy  the  peritoneum  was  found  uninflamed,  with  the  exception 
of  a  local  dry  peritonitis  around  the  seat  of  perforation,  dishing, ' 
three  cases  :  (1)  A  male,  aged  nine  years ;  perforation  at  the  end 
of  the  second  week  ;  sutured  ;  abdomen  opened  twice  subsequently, 
once  for  a  supposed  second  perforation  and  once  for  kinking  of  the 
intestine  from  adhesions ;  recovery.  (2)  A  male,  aged  eighteen 
years,  perforation  in  the  fifth  week  ;  sutured  ;  death  in  four  hours. 
(3)  A  male,  aged  thirty-one  years  ;  perforation  at  the  end  of  the 

1  Loc.  cit. 

2  Medical  and  Surgical  Reports,  Boston  City  Hospital,  1898,  p.  126. 

3  British  Medical  Journal,  1898,  vol.  ii.  p.  220. 

4  Transactions  of  the  Clinical  Society  of  London,  1898,  vol.  xxi.  p.  234. 

5  Annals  of  Surgery,  1898,  vol.  xxviii.  p.  144. 

6  Boston  Medical  and  Surgical  Journal,  1896,  vol.  cxxxix.  p.  317. 

7  Johns  Hopkins  Bulletin,  Nov.,  1898  (British  Medical  Journal,   Epit.,  Feb. 
4,  1899.) 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  139 

fourth  week  ;  sutured  ;  death  after  eight  hours.  Iu  a  fourth  case 
no  perforation  was  discovered  at  the  time  of  operation  ;  the  patient 
recovered.  Bigger  and  Campbell1  (a  ease  reported  to  the  Ulster 
Medical  Society):  A  male,  aged  thirty-six  years;  perforation 
during  the  third  week  ;  operation  after  ten  and  one-half  hours  ; 
perforation  closed  by  Lembert's  sutures  ;  death  on  the  fourth  day. 
Altogether  we  have  103  cases,  with  21  recoveries.  The  success- 
ful cases  on  record  are  as  follows  :  Mikulicz  (1884),  Wagner 
(1891),  Van  Hook  (1891),  Abbe,  JNetschajew  and  Trojanow, 
Dandridge,  Ferraresi  (1894),  Hill,  Murphy,  Price  (two  cases), 
Watson,  Sifton  (1895),  Finney,  Brunton  and  Bowlby  (1896), 
Panton  (1897),  Deaver,  Burrell  and  Bottomley,  Handford  and 
Anderson,  and  Cushing  (1898).  In  England,  including  Piatt's 
own  cases,  but  excluding  the  doubtful  case  mentioned  by  Greig 
Smith,2  thirteen  operations  are  now  on  record.  Dr.  Piatt's  own 
case  is  the  third  reported  in  that  country  in  which  the  result 
has  been  successful. 

As  this  book  goes  through  the  printers'  hands  I  find  the  follow- 
ing case  reported  by  Dr.  Hugh  M.  Taylor,3  of  Richmond,  Virginia. 

The  patient  was  a  "  little  boy,"  age  not  given,  who  suffered 
from  a  typhoid  perforation.  Operation  was  performed  fifteen 
hours  after  the  first  onset  of  symptoms.  A  quantity  of  sero- 
purulent  fluid  escaped  from  the  peritoneum  but  no  gas.  The 
perforation  was  found  in  the  lower  portion  of  the  ileum  which 
was  closed.  The  patient  recovered,  the  final  report  being  made 
four  weeks  after  the  operation  was  performed. 

The  Russian  cases  referred  to  above  are,  in  brief  detail,  as  fol- 
lows :  In  1891  Xetschajew  and  Trojanow  operated  upon  a  man 
aged  thirty-one  years,  who  presented  signs  of  perforation.  The 
operation  was  practised  six  hours  after  the  entrance  of  the  patient 
into  the  hospital.  Marked  evidences  of  serous  peritonitis  were 
found,  and  fecal  matter  was  in  the  peritoneal  cavity.  Resection 
of  the  perforated  portion  was  performed.      Death  followed,  and 

1  British  MedicalJournal,  1899,  vol.  i.  p.  89. 

2  Abdominal  Surgery,  fourth  edition,  p    77o. 

8  Virginia  Medical  Semi-monthly,  March  24,  L899. 


140     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

autopsy  revealed  typhoid  ulcers  in  the  ileum.  In  1893  the  same 
authors  operated  upon  a  man  of  twenty-eight  years,  who  presented 
similar  symptoms.  On  entering  the  hospital  a  diagnosis  of  the 
ambulatory  form  of  typhoid  fever  was  made,  with  intestinal  per- 
foration. The  operation  took  place  seventeen  hours  after  entrance. 
A  general  sero-purulent  peritonitis  was  found,  the  fluid  being  filled 
with  fibrinous  flakes.  Quite  a  large  perforation  was  present ;  4 
cm.  of  the  intestine  was  excised.  The  abdominal  wall  was  not 
immediately  sutured,  but  the  opening  in  it  was  packed  with  sterile 
gauze,  and  complete  recovery  followed. 

A  third  case  was  that  of  Kohltzoff,  and  occurred  in  a  man  of 
twenty-four  years,  who  had  typhoid  fever  and  congestion  of  the 
lungs.  He  had  symptoms  of  perforation,  with  excessive  fever. 
The  operation  was  performed  four  hours  after  the  perforation. 
Sero-sanguinolent  fluid  was  found  in  the  peritoneal  cavity,  and  20 
cm.  from  the  ileo-caecal  valve  there  was  a  perforation.  A  resec- 
tion of  the  perforated  portion  of  the  intestine  was  performed. 
Death  occurred  in  two  days.  At  the  autopsy  numerous  typhoid 
ulcers  were  found  near  the  point  of  ulceration. 

In  the  fourth  case,  belonging  to  Trojanow,  a  patient  twenty-nine 
years  of  age  had  been  sick  for  fifteen  days  with  fever.  He  was 
seized  with  violent  pain  in  the  belly,  followed  by  intense  chills, 
vomiting,  and  hiccough.  There  was  abdominrl  swelling  and  gen- 
eral pain.  The  symptoms  were  those  of  perforative  peritonitis. 
The  operation  began  sixteen  hours  after  the  accident.  Abundant 
sero-purulent  fluid  was  found  in  the  abdominal  cavity,  and  per- 
foration of  the  intestine  had  occurred  10  cm.  from  the  ileo-ca?cal 
valve.  Resection  of  the  perforated  segment  was  performed,  and 
death  occurred  fourteen  hours  afterward.  The  autopsy  revealed 
typhoid  ulcers  in  the  ileum. 

In  addition  to  these  cases  Gasselewitsch  and  Wanach  report  five 
more.  The  first  of  these  was  a  man,  thirty-six  years  of  age,  who  had 
had  typhoid  fever  fifteen  days.  After  eight  days  he  had  had  bloody 
stools,  violent  pain  in  the  belly,  followed  by  intense  chills,  vomit- 
ing, and  hiccough.  The  belly  was  swollen  and  the  pain  was  gen- 
eral.    The  pulse  was  120,  the  temperature  febrile.     An  operation 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  141 

was  performed  two  hours  after  the  perforation.  ( )n  exploring  the 
intestines  two  perforations  were  found,  one  2  cm.  in  diameter,  the 
other  much  smaller.  Twenty  centimetres  of  the  intestine  was 
resected,  and  death  followed  in  about  two  hours.  At  the  autopsy 
ten  ounces  of  fetid  pus  was  found  in  the  belly.  The  parietal  and 
visceral  peritoneum  were  covered  with  punctiform  hemorrhages. 
The  part  of  the  intestine  resected  was  37  cm.  from  the  caecum. 
Their  second  case  was  a  man  of  twenty-four  years,  who  had  been 
ill  some  time  with  typical  typhoid  fever.  Seven  days  after 
entrance  into  the  hospital  he  was  seized  with  violent  chills  and 
fever  and  all  the  symptoms  of  perforative  peritonitis.  The  opera- 
tion was  done  seventeen  hours  after  the  accident,  ether  being 
given  after  a  preliminary  injection  of  cocaine.  Perforation  of  the 
intestine  was  found.  The  mesenteric  glands  were  enlarged  and 
were  adherent  to  the  intestine  in  places.  Thirty  centimetres  of 
the  intestine  was  resected.  Death  occurred  in  six  hours  after  the 
operation.  The  autopsy  revealed  profound  typhoid  ulceration  at 
the  lower  extremity  of  the  ileum.  There  were  also  signs  of 
catarrhal  pneumonia.  The  third  case  was  in  a  young  man  of 
nineteen  years,  who  had  been  sick  five  days.  His  fever  was  high, 
and  he  had  bloody  stools.  Four  weeks  after  his  entrance  into  the 
hospital  he  had  perforation  of  the  intestine.  His  condition  re- 
mained grave,  and  on  opening  the  peritoneal  cavity  it  was  found 
to  be  filled  with  bloody  fluid,  and  there  were  intestinal  adhesions. 
Death  occurred  in  three  days.  Again,  the  autopsy  revealed  per- 
foration and  ulceration.  A  man  of  twenty-seven  years  presented 
mild  symptoms  of  typhoid  fever.  Six  days  after  his  entrance  he 
was  seized  with  violent  pain  in  the  belly  and  with  chills  and 
sweating.  There  was  also  meteorism.  Twenty-four  hours  after 
these  symptoms  the  operation  was  performed.  Again  the  belly 
was  found  filled  with  sero-purulent  fluid.  Thirty  centimetres  of 
the  intestine  was  removed  and  contained  four  ulcers.  Notwith- 
standing injections  of  saline  solution  the  patient  died  eight  hours 
after  operation.  Again  the  autopsy  confirmed  the  diagnosis.  In 
the  fifth  case  a  man  of  twenty-nine  years  entered  on  the  seventh 
day  of  typhoid    fever;    six  days  later  violent    pain    in    the   caeca! 


142     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

region  carne  on,  with  moderate  fever.  Surgical  intervention  took 
place  thirteen  hours  after  the  accident.  The  abdominal  cavity 
was  filled  with  serous  fluid.  The  walls  of  the  intestines  were 
cedeniatous.  Resection  was  performed.  Death  occurred  in  three 
days.  The  autopsy  revealed  the  characteristic  lesions  and  pneu- 
monia of  both  bases  of  the  lungs.  Altogether,  these  authors 
quote  seventy-one  instances  of  perforation  in  the  course  of  typhoid 
fever,  with  seventeen  recoveries. 

The  number  of  deaths  in  operation  for  perforative  peritonitis 

in  typhoid  fever  is  necessarily  high. 

In  summing  up  his  views  on  the  question  of  operative  inter- 
ference, Keen  says  :  "  Mr.  Gairdner,  Assistant  Physician  of 
the  Belvidere  Fever  Hospital,  in  analyzing  forty-seven  cases  of 
peritonitis  in  typhoid  fever  with  reference  to  surgical  interference, 
in  a  very  careful  and  judicious  paper  in  the  Glasgow  Medical  Journal, 
February,  1897,  page  67,  reaches  the  following  conclusions,  which 
well  express  my  own  feelings,  and  it  is  all  the  more  worthy  of 
consideration  as  the  opinion  of  a  thoughtful  physician  rather  than 
that  of  an  over-sanguine  surgeon  :  '  The  treatment  of  peritonitis 
in  the  course  of  enteric  fever  by  laparotomy  has  hitherto  had  a 
moderate  success.  There  is  every  reason  to  believe  that  greater 
success  is  possible,  and  in  any  case  the  results  are  better  than 
those  of  any  other  treatment.  Laparotomy  offers  a  fair  chance  to 
about  49  per  cent,  of  cases,  Avhile  19  per  cent,  of  the  whole  would 
certainly  have  a  good  chance.  Nothing  but  experience  can  deter- 
mine what  the  results  will  be  —better  or  worse  than  might  be 
expected  prima  facie.  If  there  is  a  good  cause  at  least  for 
attempting  surgical  interference,  it  becomes  incumbent  on  the 
profession  to  afford  every  facility  for  making  the  attempt.  This, 
of  course,  applies  particularly  to  authorities  responsible  for  hos- 
pitals in  which  enteric  fever  is  treated.'  " 

My  own  feeling  in  this  matter  is  well  summed  up  in  the 
words  of  Mikulicz,1  who  said  at  Magdeburg  in  1884  :  "  If  suspi- 
cious of  a  perforation  one  should  not  wait  for  an  exact  diagnosis. 

1  Quoted  by  Thayer  in  Progressive  Medicine,  1899,  vol.  i. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  143 

and  for  peritonitis  to  develop  to  reach  a  pronounced  degree,  but, 
on  the  contrary,  one  should  immediately  proceed  to  an  exploratory 
operation,  which  in  any  ease  is  free  from  danger."  Again,  dish- 
ing1 says  :  "  When  the  diagnosis  is  made,  operation  is  indicated 
whatever  the  condition  of  the  patient.  As  Abbe's  case  exemplifies, 
no  case  may  be  too  grave.  A  precocious  exploration  from  an 
error  in  diagnosis  is  not  followed  by  untoward  consecpiences,  such 
as  must  invariably  be  expected  after  a  neglected  and  tardy  one." 
The  only  modification  I  would  make  of  these  two  opinions  is  that 
in  sudden  acute  cases  followed  by  speedy  collapse,  the  patient 
should  be  given  sufficient  time  to  rally  before  the  operation  is 
performed. 

The  relation  of  typhoid  fever  to  appendicitis  is  one  of  great 
interest.  It  has  been  thought  by  some  that  appendicitis  arising 
in  typhoid  fever  was  a  mere  coincidence ;  by  others  that  its 
origin  depended  upon  a  general  infectious  process,  and,  again, 
by  others,  that  it  was  due  to  the  direct  infection  with  the 
bacillus  of  Eberth.  Probably  all  these  views  hold  true  in  indi- 
vidual cases.  The  richness  of  the  appendix  in  lymphoid  tissue, 
and  the  fact  that  typhoid  fever  is  particularly  prone  to  attack 
such  tissues,  renders  this  organ  peculiarly  susceptible  ou  theo- 
retical grounds.  That  this  view  is  correct  is  proved  by  the 
research  of  Hopfenhausen,2  who  preserved  the  appendices  obtained 
from  thirty  cases  of  typhoid  fever  and  studied  them  under  Stilling 
in  the  University  of  Lausanne.  She  concludes  that  moderate 
changes  in  the  appendix  may  be  found  in  nearly  all  cases  of  this 
character,  and  that  it  is  most  marked  in  the  earlier  stage  of  the 
malady,  and  consists  chiefly  in  cellular  infiltration,  specific  lesions 
being  rare  and  not  being  sufficient  to  produce  the  more  severe 
forms  of  appendicular  disease. 

True  appendicitis  complicating  typhoid,  in  the  sense  of  inflam- 
mation of  this  part  severe  enough  to  produce  abscess,  is  undoubt- 
edly a  very  rare  affection.     One  such  case  is  reported  further  on, 

1  Johns  Hopkins  Hospital  Bulk-tin,   1S!)S,  vol.  i\.  p.  -J.">7. 

2  Revue  Med.  de  la  Suisse  Romande,  February  '20,  lS'J'.i. 


144     COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER.. 

as  occurring  in  ray  own  practice.  Here  a  large  abscess  containing 
over  a  pint  of  pus,  having  the  odor  of  a  typhoid-fever  stool,  was 
allowed  to  escape  by  an  incision.  Recovery  occurred.  In  more 
frequent  instances  the  appendix  is  the  seat  of  typhoid  ulcers,  or 
an  ulcer,  although  the  recorded  cases  in  which  this  lesion  has  been 
found  are  surprisingly  few.  This  scantiness  of  reports  is  prob- 
ably due  in  large  part  to  the  fact  that  the  appendix  is  not  care- 
fully examined  for  lesions  in  making  autopsies,  for  in  the  cases 
with  which  I  am  acquainted  in  which  the  appendix  has  been  care- 
fully examined,  appendicular  lesions  have  been  surprisingly  fre- 
quent. At  a  recent  meeting  of  the  Pathological  Society  of  Phila- 
delphia Stengel  made  a  verbal  report  of  several  instances  in 
which  typhoid  ulcer  had  been  found  in  the  appendix,  as  did  also 
Sailer,  and  in  a  paper  on  typhoid  ulcer  of  the  oesophagus,  Ries- 
man  incidentally  mentioned  appendicular  typhoid  ulcer  as  being 
also  present  in  his  case. 

Keen  has  well  said,  therefore,  in  his  essay,  that  in  all  cases  of 
operation  for  intestinal  perforation  in  typhoid  fever  the  surgeon 
should  examine  the  appendix  to  discover  if  it  is  diseased.  In 
Keen's  table  of  operations  done  for  intestinal  perforation,  cases 
of  associated  appendicular  lesions  are  recorded  by  Bontecou,1 
Kimura,2  and  Alexandroff3  (there  were  three  large  perforations  of 
the  appendix  in  this  case). 

Additional  cases  have  been  chiefly  collected  by  Kelynack,4  who 
points  out  that  Murchison5  saw  two  cases  of  appendicular  ulcera- 
tion, one  in  a  girl  of  thirteen  years,  four  ulcers  being  present. 
Two  small  perforations  were  found  in  it.  "Nornian  Moore6  records 
four  cases.  Death  was  due  in  two  of  them  to  perforation  of  the 
appendix ;  another  had  an  ulcer  at  the  tip  of  the  organ.  Fitz 
found  in  257  cases  of  appendicular  perforation  only  three  due  to 

1  Journal  of  American  Medical  Association,  January  28,  1888,  p.  106. 

2  Sei-i-kwai  Medical  Journal,  1890,  ix.  55. 

3  Report  of  Hospital  St.  Olga,  in  Moscow,  1890,  198. 

4  Pathology  of  the  Vermiform  Appendix,  London,  1892. 

5  The  Continued  Fevers,  2d  ed.,  1873,  p.  623,  and  Trans.  Pathological  Society, 
London,  1866,  xvii.  p.  127. 

6  Trans.  Pathological  Society,  London,  1883,  xxxiv.  113. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  145 

typhoid  fever,  and  in  a  later  paper/  in  167  cases  five  instances 
with  this  lesion.  All  these  quotations  throw  light  on  this  matter, 
but  the  reports  of  Morin2  and  HeschP  give  a  much  higher  per- 
centage. Thus  Morin,  in  (57  collected  cases,  finds  12  examples  of 
appendicular  perforation,  or  18.75  per  cent.,  and  Heschl,  in  56 
cases,  found  this  lesion  in  S,  or  14.3  per  cent.  McArdle4  has  also 
reported  a  case. 

Contrary  to  the  view  held  by  some,  that  perforation  of  the 
appendix  often  occurs  in  typhoid  fever,  it  is  to  be  recalled  that 
Fitz  in  one  of  his  early  investigations  was  only  able  to  find  three 
cases  in  which  this  accident  occurred  as  the  result  of  typhoid  fever. 
More  recently  Fitz  has  collected  five  cases  in  167  cases  of  perfo- 
ration due  to  typhoid  fever.  On  the  other  hand,  perforation  in 
this  part  is  more  apt  to  be  followed  by  recovery  than  elsewhere, 
and  this  may  explain  why  it  is  that  the  best  post-mortem  records 
are  so  scant  in  this  respcet.  Fitz  asserts  that  the  more  closely 
the  symptoms  of  perforation  resemble  those  of  appendicitis  the 
more  favorable  is  the  prognosis. 

Eolleston5  states  that  in  14  out  of  60  cases  of  enteric  fever 
seen  at  St.  George's  Hospital,  London,  changes  were  found  in  the 
appendix.  In  5  there  was  tumefaction,  in  7  ulceration,  and  in  2 
perforation.  Perforation  of  the  bowel  occurred  in  18  of  these  60 
cases — a  very  high  percentage. 

In  the  very  interesting  paper  by  Hopfenhausen6  on  this  topic, 
already  quoted,  she  tells  us  that  she  collected  statistics  con- 
cerning the  appendix  in  808  cases  which  came  to  autopsy  in  St. 
Petersburg,"  and  found  perforation  of  the  appendix  in  eight  cases. 
In  one  of  these  the  perforation  had  caused  perityphlitis,  found 
post-mortem  ;  in  two  others  the  diagnosis  was  made  in  life.      In 

1  Trans,  of  Association  of  American  Physicians,  1891. 

2  These  de  Paris,  1869.  3  Schmidt's  Jahrbucher,  1853,  lxxx.  p.  42. 

4  Trans.  Royal  Academy  Medicine,  Ireland,  1888,  vi.  392. 

5  Lancet,  1898,  vol.  i.  p.  1401. 

6  Revue  Med.  de  la  Suisse  Romande,  February  20,  1899.  Etude  sur  l'etat  et 
l'appendice  vermiforme  dans  le  cours  de  la  tievre  typhoide. 

7  Protocoles  des  instituts  pathologique  de  l'Hdpital  Municipal  d'Obouchow, 
et  de  l'Hdpital  Municipal  de  Ste  Marie-Madeleine,  1S89-1897. 

10 


146     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

117   cases  general  peritonitis  was  found,  and  in  109   this  was 
attributed  to  intestinal  perforation. 

In  all  probability  typhoid  fever  predisposes  a  patient  to  appen- 
dicitis. Keen  has  hinted  at  this  without  adducing  any  statistics 
to  prove  it,  and  cases  can  be  found  in  literature  which  point  to  it. 
In  the  cases  collected  by  Hopfenhausen,1  we  find  this  subject 
also  discussed.     She  found  the  following  statistics  : 


Hopital  cantonal  de  Lausanne 

Sonnenburg 

Pozzi 

Bull 

Hecker 

Bossard 

Douneff 

Le  Guern 

Jacobson  . 

Schnellen 

Langheld 

Hohn       . 

Jacob 

Total 


No.  of 

No.  of 

cases  proceed- 

cases 

ing  from 

observed 

typhoid  fever. 

9 

200 

6 

130 

1 

1 

3 

12 

1 

35 

2 

26 

4 

52 

1 

110 

2 

6 

1 

32 

4 

112 

1 

2 

2 

25 

37 


743 


The  interval  between  the  two  diseases  in  these  cases  was  gener- 
ally so  long  that  the  figures  disprove  the  relationship  rather  than 
prove  it.  Thus,  in  5  cases  it  followed  in  from  twenty-five  to 
forty  years ;  in  24  from  ten  to  twenty  years  ;  in  2  cases  in  three 
years ;  in  1  in  two  years ;  in  1  in  one  year ;  in  3  from  three  to 
six  months ;  in  1  during  typhoid  fever. 

In  only  one  instance  was  the  appendicitis  near  enough  to  the 
attack  of  typhoid  fever  to  bear  the  true  relationship  of  cause  and 
effect,  namely,  that  of  Bossard,2  in  which  perityphlitis  followed 
in  the  same  month. 


1  Kevue  Medicale  de  la  Suisse  Komande,  February  20,  1899. 

2  Uber   die   Verchwarung  und    Durchborung   des   Wurmfortsatzes. 
Zuricb,  1869. 


Thesis, 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  147 

The  history  of  my  own  case,  to  which  reference  has  already  been 
made,  was  as  follows  :  On  March  23,  1898,  J.  R.,  aged  forty-three 
years,  called  on  me  with  the  statement  that  he  was  suffering  with 
general  malaise  and  aching  all  over  the  body,  and  thought  that 
he  must  have  caught  a  severe  cold.  Two  days  later,  March  25th,  I 
was  sent  for  to  go  to  his  house,  and  found  him  with  a  temperature 
of  102°.  He  also  complained  of  a  little  more  soreness  upon  the 
right  side  of  his  body  than  upon  the  left,  but  this  was  not  par- 
ticularly localized.  As  he  had  a  history  of  an  obscure  attack  of 
appendicitis  eighteen  months  before,  an  attack  in  which  he  asserted 
that  there  was  swelling  but  no  pain  in  the  right  iliac  fossa,  I  made  a 
careful  examination  of  the  region  of  the  appendix,  but  was  unable 
to  discover  any  induration  and  but  slight  tenderness,  with  a  good 
deal  of  gurgling.  His  temperature  from  this  time  continued  to 
rise,  and  the  pain  in  the  neighborhood  of  the  appendix  increased, 
but  at  no  time  was  it  very  severe. 

On  the  26th  I  asked  Dr.  W.  W.  Keen  to  see  him  with  me  in 
consultation,  but  neither  of  us  could  determine  that  there  was 
any  inflammation  of  the  appendix.  The  fever  continued  high, 
his  condition  became  worse,  and  on  Monday,  April  4th,  I  asked 
Dr.  Musser  to  see  him  with  me  in  consultation,  as  there  had 
developed  in  the  right  iliac  region  an  increased  tenderness,  some 
pain  on  extension  of  the  leg,  and  the  patient  was  unable  to  lie 
upon  that  side.  Nothing  connected  with  the  appendix  could, 
however,  be  discovered,  but  as  there  was  considerable  bulging  in 
a  line  drawn  between  the  axilla  and  the  anterior  superior  spine 
of  the  ilium,  and  as  this  swelling  evidently  contained  pus,  it  was 
decided  that  an  operation  was  needed,  and  I  asked  Dr.  Keen  to 
see  the  case.  Dr.  Keen  agreed  in  the  diagnosis,  and  on  Saturday, 
April  8th,  he  made  an  incision  from  which  escaped  about  a  pint 
and  a  half  of  exceedingly  offensive  pus,  with  a  distinctly  typhoidal 
odor.  The  stools  prior  to  the  operation  had  been  somewhat 
typhoidal  in  character,  the  odor  of  his  body  was  that  of  typhoid 
fever;  he  had  developed  a  number  of  rose  spots  on  his  abdomeo 
and  back,  and  the  appearance  of  his  tongue  was  characteristic.  An 
examination  of  his  blood  before  operation  revealed  a  considerable 


148     COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER. 

number  of  leucocytes,  probably  clue  to  the  abscess  formation,  and 
gave  an  imperfect  Widal  reaction.  In  the  abscess  cavity  there 
was  found  a  considerable  mass  of  tissue  about  the  size  of  my 
thumb  which  was  at  first  thought  to  be  a  sloughed  off  appendix, 
but  which  on  careful  examiuation  by  Dr.  Keen  apparently  con- 
sisted of  a  piece  of  omentum  which  had  been  cut  off  from  the 
general  peritoneal  cavity. 

After  the  operation  the  patient's  temperature  rapidly  fell  so 
that  it  reached  the  normal  point  in  a  few  days,  and  while  he  was 
exceedingly  ill  for  some  days  prior  to  and  after  the  operation,  he 
ultimately  made  a  perfect  recovery. 

An  iuoculation  was  made  from  the  appendix  on  April  16th. 
The  tube  bore  the  date  of  April  9th,  and  contained  =-a  growth  at 
the  time  it  was  received.  Stains  of  the  growth  and  of  subsequent 
cultures  showed  a  short  thick  bacillus  with  rounded  ends,  usually 
single,  some  holding  together  in  pairs  or  short  threads  of  three 
to  six  bacilli.  Also  a  few  bacilli  about  the  same  length  as  the 
above,  but  much  thinner  and  with  a  tendency  to  form  longer 
threads.  They  stained  readily  with  the  ordinary  aniline  dyes.  If 
stained  for  only  two  minutes  little  light  granules  on  the  side  and 
near  the  end  were  observed,  but  if  stained  longer  they  also  reacted 
to  the  stain.  These  spots  failed  to  react  to  stains  for  spores, 
and  were  probably  granular  areas.  By  their  growth  and  reaction 
to  stain  they  correspond  to  the  bacillus  coli  communis  and  proteus 
vulgaris. 

A  second  case  without  abscess  was  that  of  a  boy  of  nine  years, 
who  because  of  ill  health  had  been  taken  to  the  seashore,  with  the 
hope  that  it  would  benefit  him.  During  the  first  week  at  Atlantic 
City  he  suffered  from  continued  fever,  ranging  from  102°  to  103°, 
for  which  no  adequate  cause  could  be  discovered.  His  fever  then 
disappeared  suddenly,  and  was  absent  for  a  week,  during  which 
time  he  ate  heartily  and  seemed  to  improve  greatly  in  health. 
During  his  third  week  at  Atlantic  City,  however,  the  fever 
returned  hi  an  irregular  form,  and  he  complained  at  times  of 
violent  pain  in  his  abdomen.  Two  days  after  his  return  to  Phila- 
delphia I  saw  him.     At  this  time  there  was  marked  tenderness 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  149 

in  the  right  iliac  fossa,  particularly  in  the  neighborhood  of 
McBurney's  point,  and  also  posteriorly,  back  of  the  appendix. 
There  was  also  some  rigidity  of  the  muscles  on  the  right  side  over 
the  appendix.  His  temperature  varied  from  103°  to  104°,  but 
he  was  not  particularly  restless.  His  tongue  was  fairly  clean,  but 
there  was  a  complete  loss  of  appetite.  At  this  time,  the  appen- 
dicular trouble  did  not  seem  sufficient  to  account  for  his  high 
temperature,  but  a  careful  examination  of  every  organ  of  his  body 
and  of  the  blood  failed  to  reveal  any  cause  for  the  pyrexia.  At 
the  end  of  the  first  week  in  bed  his  tongue  became  foul,  his  lips 
covered  with  sordes,  the  temperature  on  one  or  two  occasions  rose 
nearly  to  105°,  and  he  developed  the  typical  rose  spots  of  typhoid 
fever,  the  appendicular  irritation  and  inflammation  having  been 
treated  during  the  preceding  week  by  the  application  of  ice-bags. 
One  week  after  the  symptoms  of  typhoid  fever  became  well 
marked,  distinct  appendicular  tenderness  partly  disappeared,  and 
at  the  end  of  the  third  week  had  entirely  disappeared. 

These  two  cases  are  of  interest  because  they  illustrate  the  fact 
that  it  is  sometimes  necessary  to  make  a  differential  diagnosis 
between  typhoid  fever  and  appendicitis,  and  also  because  they 
illustrate  the  fact  that  typhoid  fever  and  appendicitis  may  exist 
side  by  side.  Possibly  in  one  or  both  of  these  cases  the  appen- 
dicular trouble  arose  from  the  typhoidal  affection. 

Nervous  System  in  the  Developed  Stage  of  the  Disease. 
Delirium.  The  nervous  disturbances  of  this  period  vary  very 
greatly.  In  the  average  case  there  is  in  the  early  part  of  the  onset 
no  mental  change,  save  that  of  unfitness  for  mental  occupation,  with 
dreamful  sleep  which  is  apt  to  be  restless.  Later  the  patient  con- 
tinually doses  off,  yet  awakens  easily,  and  for  a  moment  may  be 
a  little  confused  between  the  mental  impressions  left  on  his  brain 
by  the  dream  and  the  conditions  he  finds  about  him  on  returning 
to  consciousness.  Still  later,  if  the  attack  is  marked,  he  becomes 
more  apathetic  when  awake,  less  easily  aroused  when  asleep,  and 
often  delirious  in  his  sleep,  his  dreams  being  evidently  vivid,  so 
that  he  keeps  muttering  the  conversation  lie  thinks  he  is  actually 
having,  or  calls  out    loudly,  as  his  dream  seems   to   lead    him  to  a 


150     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

point  where  an  imperative  call  or  sudden  action  is  needed.  Some- 
times the  delusions  in  the  delirium  amount  to  imperative  concep- 
tions, and  the  patient  believes  that  he  is  away  from  home  and  must 
return  there  at  once,  or  that  he  is  being  restrained  by  force,  or, 
again,  that  some  member  of  his  family  is  in  distress  and  needs  his 
aid  or  is  calling  for  him.  Often  in  parents  and  in  young  persons 
this  form  of  mental  disturbance  is  painful  to  witness,  difficult  to 
overcome,  and  harassing  to  the  patient.  In  these  cases  the  hands 
may  be  moved  continually  in  active  motions,  as  if  to  illustrate  the 
views  of  the  patient.  Such  cases  are  apt  to  be  grave  if  for  no 
other  reason  than  that  they  exhaust  themselves  if  relief  is  not 
given.  The  more  encouraging  type  of  delirium  is  of  the  quiet, 
muttering  form,  as  if  the  patient  was  gently  "  speaking  in  his 
sleep  "  as  in  health,  and  this  may  be  taken  as  the  natural  form  of 
delirium  in  the  disease.  Later  the  stupid  condition  becomes  more 
and  more  marked  in  some  cases,  and  absolute  mental  stillness 
is  reached,  in  which  only  hard  shaking  or  loud  calling  will  arouse 
the  patient. 

On  the  other  hand,  even  in  severe  cases  the  mental  state  often 
remains  but  little  disturbed  throughout  the  entire  illness,  and  in 
the  majority  the  beginning  mental  apathy  is  largely  put  aside  by 
the  proper  use  of  cold  sponging  or  plunging. 

Aside  from  the  mental  hebetude  of  most  cases  of  typhoid  fever 
which  may  be  considered  to  represent  the  ordinary  mental  signs 
of  this  disease,  we  may  have  remarkable  clearness  of  intellect,  so 
that  at  no  time,  even  when  waking  from  a  heavy  sleep,  is  the 
patient's  mind  clouded.  On  the  other  hand,  it  is  a  curious  fact 
that  some  of  these  patients  who  seem  to  be  mentally  clear  all 
through  an  attack,  state  after  it  is  over  that  they  have  a  very 
indistinct  recollection  of  the  occurrences  that  took  place. 

There  can  be  no  doubt  that,  as  a  rule,  the  mental  state  is  a  fair 
index  to  the  severity  of  the  malady,  and,  therefore,  the  greater  the 
perversion  of  the  mental  process  the  more  grave  the  prognosis. 
So  far  as  delirium  itself  is  concerned,  Liebermeister  found  that  in 
983  cases  without  noteworthy  brain  symptoms  only  about  3.5  per 
cent,  died;  that  in  191  cases  with  mild  delirium  at  times,  19.8 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  151 

per  cent,  died,  and  in  43  cases  in  which  stupor  or  coma  was  pres- 
ent, 70  per  cent.  died.  Delirium  is  a  grave  symptom  in  typhoid 
fever  in  direct  proportion  to  its  severity.  Zenner1  asserts  that  in 
cases  of  severe  delirium  the  mortality  reaches  50  per  cent.,  and 
when  the  delirium  is  complicated  with  stupor,  almost  70  per  cent.; 
that  the  mortality  of  initial  delirium  approximates  30  per  cent., 
while  that  occurring  during-  the  first  week  of  the  fever  is  over  40 
per  cent.  It  seems  to  the  writer  that  these  statistics  give  a  false 
impression  as  to  the  danger  of  these  symptoms  of  the  disease. 
These  figures,  however,  express  the  gravity  of  marked  mental 
symptoms,  and  also  throw  light  on  the  relative  frequency  of  the 
mild  and  severe  affections  of  the  brain. 

Delirium  is  largely  dependent  upon  the  susceptibility  of  the 
individual  to  the  infection  and  to  the  febrile  movement.  Many 
persons  are  readily  made  "  flighty,"  to  use  the  popular  term,  by 
fever  of  less  than  103°,  while  others  withstand  greater  fever  than 
this  with  impunity.  A  delirium  in  a  child,  of  the  active  talkative 
or  complaining  type,  does  not  possess  grave  significance  if  the 
fever  be  high  enough  to  be  its  cause,  since  the  mental  disturbance 
is  probably  due  to  the  temperature,  or  if  this  symptom  occurs  in 
a  nervous  woman  or  man  it  is  not  of  great  importance  unless  it 
be  so  persistent  and  long  continued  that  the  loss  of  sleep  and 
rest  exhausts  the  patient. 

A  form  of  delirium,  usually  seen  in  hysterical  women  and  chil- 
dren, which  resembles  the  condition  of  the  patient  suffering  from 
belladonna  poisoning,  sometimes  occurs,  in  which  there  is  much 
restlessness  and  tossing  of  the  body,  with  great  volubility  and 
incoherent  screaming,  which  may  seem  most  alarming,  but 
which  is  not  as  dangerous  an  omen  as  its  severity  would  indi- 
cate. As  it  is  usually  seen  in  the  early  stages  it  in  no  wise  is 
indicative  of  profound  nervous  exhaustion,  but  rather  of  an  ill- 
balanced  nervous  system  upset  by  the  nervous  disturbance  of  the 
infection. 

In  severe  cases  that  condition  of  ceaseless  mental  activity  in  a 

1  American  Lancet,  January,  1889. 


152     COMPLICATIONS  AND  SEQTJELJE  OF  TYPHOID  FEVER. 

semi-stuporous  mind,  called  "  coma  vigil/'  is  often  present.  It  is 
an  indication  of  grave  infection,  as  a  rule. 

Striimpel  asserts  that  "  actual  insanity  is  not  infrequent  during 
the  course  of  typhoid  fever,"  and  that  it  generally  takes  the  form 
of  a  melancholia.  Taty1  records  a  case  of  what  he  calls  the  mel- 
ancholic form  of  typhoid  fever,  the  diagnosis  being  confirmed  by 
the  Widal  action  and  other  characteristic  symptoms.  The  patient 
was  restless,  had  loss  of  appetite,  was  delirious  upon  anarchistic 
questions,  and  had  great  mental  depression.  There  was  absolute 
mutism  when  she  was  examined,  and  she  refused  both  food  and 
drink,  but  sleep  was  relatively  good.  In  another  case  there  were 
visual  hallucinations  and  delirium,  with  melancholic  conceptions, 
and  vague  ideas  of  persecution.  Striimpel  also  records  a  case  of 
hysterical  insanity  in  a  young  girl,  which  broke  out  during  the 
course  of  the  fever.  (For  post-typhoid  insanity,  see  last  chapter, 
by  Dr.  Dercum.) 

Hysterical  convulsions  have  been  recorded  as  complicating  the 
developed  stage  of  typhoid  fever ;  thus  Remond  and  Coumenges2 
record  two  cases  of  this  character.  In  one,  a  young  woman  of 
distinctly  neurotic  character,  who  had  never  suffered  from  convul- 
sions however,  developed  on  the  fifteenth  day  of  the  disease 
unconsciousness,  a  thready  pulse,  embarrassed  respiration,  and 
severe  hiccough,  so  that  the  physician  thought  the  patient  was 
about  to  die,  when  the  scene  suddenly  changed,  the  body  was 
stiffened,  and  a  violent  hysterical  convulsion  came  on.  Repeated 
attacks  occurred  on  subsequent  days  until  death  occurred  from 
exhaustion. 

The  headache,  usually  frontal  and  severe,  in  the  early  days  of 
onset,  may  continue  as  an  annoying  symptom  all  through  the 
attack,  but  rarely  possesses  its  severe  characteristics  after  the  first 
week.  Under  certain  circumstances,  however,  it  becomes  severe, 
and  is  worthy  of  relief  and  study,  since  it  may  be  due  to  perios- 
titis of  the  skull,  to  abscess  of  the  middle  ear  or  brain,  or  to 
urremia.    A  combination  of  more  or  less  active  delirium  with  rest- 

1  Lyon  Medicale,  1897,  p.  291.  2  Medical  Bulletin,  June,  1895. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  153 

lessness  and  disturbed  sleep  and  severe  pain  in  the  head  should 
make  a  careful  search  for  a  local  cause  necessary.  In  other  cases 
the  pain  extends  from  the  head  down  the  spine,  even  to  the 
sacrum,  and  from  there  down  the  legs,  particularly  along  the  pos- 
terior parts  and  in  the  bones.  This  pain  is  chiefly  seen  in  onset 
and  in  the  early  stages,  and  is  generally  absent  by  the  third  week. 

Hysterical  symptoms  may  be  present  in  children.  Thus  De 
Witt1  reports  the  case  of  a  boy  of  twelve  years,  who  suffered  on 
the  twenty-third  clay  from  marked  hysterical  symptoms,  supra- 
orbital neuralgia,  and  pain  and  stiffness  in  the  back,  the  symp- 
toms coming  on  simultaneously  with  high  temperature. 

Meningitis.  Rarely  in  the  course  of  typhoid  fever  of  the 
uncomplicated  form  symptoms  of  irritation  or  inflammation  of  the 
meninges  of  the  brain  develop,  and  it  is  important  to  remember 
that  these  symptoms  may  arise  from  several  causes.  The  most 
common  of  these  is  congestion  and  engorgement  of  the  meningeal 
vessels  without  any  true  inflammatory  process,  the  next  most  com- 
mon form  is  that  due  to  the  extension  of  an  infection  from  abscess 
in  the  middle  ear ;  the  third  form  is  that  in  which  there  is  infec- 
tion with  the  streptococcus  or  pneumococcus,  and  very  rarely  do 
we  find  a  meningitis  due  to  the  bacillus  of  Eberth.  Osier  records 
three  cases  in  which  he  made  autopsies  in  suspected  typhoid  men- 
ingitis and  found  no  true  inflammation,  and  as  long  ago  as  1839 
Taupin  called  attention  to  the  difference  at  autopsy  between  the 
appearance  of  the  meninges  of  the  brain  in  death  with  meningeal 
symptoms  due  to  typhoid  fever  and  those  due  to  true  meningitis. 
In  typhoid  fever  in  children  he  states  that  the  condition  is  one  of 
effusion  without  hyperemia. 

Keller2  asserts  that  true  meningitis  in  a  child  can  be  differ- 
entiated from  typhoid  fever  with  meningeal  symptoms  by  the  fact 
that  "  Kernig's  sign  "  is  present  in  meningitis  and  absent  in  en- 
teric fever.  This  sign  consists  in  placing  the  child  in  the  position 
of  dorsal  decubitus  with  the  legs  in   complete  extension.      After 

1  Bulletin  de  l'Academie  Royal  de  Me"decine  de  Belgique,  November  17,  1889. 

2  Revue  des  Maladies  de  I'Enfance,  September,  1898,  p.  450. 


154     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

this  is  done  the  patient  is  raised  to  the  sitting  posture,  when  if 
meningitis  be  present  the  knees  become  flexed  and  cannot  be 
straightened  until  the  child  is  once  more  flat  upon  its  back. 

Meningitis  in  children  complicating  typhoid  fever  was  written 
upon  as  long  ago  as  1825  by  Senn,1  of  Geneva.  Three  of  his 
cases  are  evidently  cases  of  typhoid  fever,  while  in  others  there 
is  doubt  as  to  their  authenticity,  and  there  is  still  less  evidence 
that  real  meningitis  was  actually  present,  even  though  the  symp- 
toms were  those  of  meningeal  irritation. 

These  meningeal  symptoms  vary  greatly  in  their  severity 
accordiDg  to  the  meningeal  lesions  which  may  be  present.  In 
the  majority  of  instances  the  chief  signs  are  headache,  delirium, 
some  muscular  rigidity,  particularly  in  the  neck,  and,  it  may  be, 
"  lead-pipe  "  rigidity  in  the  arms  and  legs.  In  other  instances 
the  patient  is  too  deeply  stupefied  by  the  poison  of  the  disease  to 
complain  of  headache,  but  may  show  its  presence  by  rubbing  his 
hands  over  his  head  and  groaning,  after  which  he  may  pass  into 
coma,  which  deepens  until  death  occurs.  Very  rarely  does  the 
pure  symptom-complex  of  true  acute  meningitis  develop,  and 
until  the  characteristic  squint,  retraction  of  the  head  and  pupillary 
signs  are  present,  the  physician  must  not  hasten  to  a  diagnosis  of 
meningitis. 

On  the  other  hand,  the  symptoms  already  named  may  be  so 
typical  that  if  the  patient  is  brought  to  a  hospital  late  in  his 
illness  without  a  history,  he  may  present  so  little  of  the  typhoid 
appearance  and  so  much  that  of  meningitis  that  a  mistake  in  diag- 
nosis is  readily  made.  To  quote  Hirt,2  "  Of  all  diseases  typhoid 
fever  is  most  likely  to  be  taken  for  meningitis,"  and,  again,  he 
tells  us  that  "  Ave  might  believe  that  at  least  the  characteristic 
temperature-curve,  the  splenic  enlargement,  and  the  rose  spots 
would  be  sufficient  to  make  a  mistake  impossible ;"  but  this  is  by 
no  means  always  the  case ;  there  are  instances  in  which  typhoid 
fever  cannot  with  certainty  be  excluded,  and  then  the  differential 
diagnosis  is  simply  impossible. 

1  Recherches  sur  la  Meningite  Signe  des  Enfants,  1825. 

2  Nervous  Diseases,  American  edition,  p.  18. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  155 

So  certain,  however,  is  Money1  of  the  assertion  of  Hughlings 
Jackson,  that  the  knee-jerk  is  not  absent  in  typhoid  fever,  that 
he  uses  this  sign  as  a  point  in  differential  diagnosis.  Thus  in 
tubercular  meningitis  he  states  that  it  disappears  and  then  reap- 
pears every  few  days,  and  that  this  inconsistency  of  the  reflex 
favors  the  diagnosis  of  tubercular  meningitis  rather  than  typhoid 
fever. 

The  possibility  of  confusing  meningitis  or,  rather,  meningeal 
symptoms  with  those  of  typhoid  fever  was,  however,  discussed  by 
Taupin  in  1839,  and  he  points  out  that  in  such  cases  the  patient 
has  in  meningitis  due  to  typhoid  fever  no  convulsions,  no  strabis- 
mus, and  no  paralysis,  whereas  the  child  with  true  meningitis  has 
all  these  signs,  and  in  addition  a  variable  pulse,  a  scaphoid  belly, 
an  absence  of  pulmonary  catarrh,  and  a  face  which  is  alternately 
red  and  pale. 

As  an  illustration  of  the  rarity  of  true  typhoid  meningitis,  how- 
ever, it  is  of  interest  to  note  that  from  1855  to  1887  there  are  only 
five  cases  of  this  affection  referred  to  in  the  Index  Catalogue  of  the 
Surgeon-General's  office,  and  as  none  of  these  were  tested  bacteri- 
ologically  they  cannot  be  considered  bona  fide.  That  meningitis 
due  to  any  cause  in  typhoid  fever  is  rare  is  shown  by  the  fact  that 
out  of  2000  cases  iu  Munich,  only  eleven  are  recorded  as  suffer- 
ing from  meningitis.  Still  more  rarely  is  the  meningitis  due  to 
the  bacillus  of  Eberth,  for  Wolff,2  in  174  cases  of  typhoid  fever 
which  were  subjected  to  bacteriological  examination,  only  found 
2.87  per  cent,  in  which  the  specific  bacillus  could  be  found  in  the 
meninges.  Within  the  last  two  years  this  subject  has  been  admir- 
ably discussed  by  Ohlmacher,3  of  Ohio,  and  by  Keen,4  of  Phila- 
delphia. Ohlmacher  himself  records  two  cases  in  which  during 
the  course  of  typhoid  fever  meningeal  symptoms  developed,  and 
in  which  careful  bacteriological  research  revealed  beyond  all 
doubt  the  bacillus  of  Eberth  in  the  meninges.     In  still  another 

1  The  Lancet,  1889. 

2  Berliner  klinische  Wochenschrift,  1897,  No.  10. 

.  3  Journal  of  the  American  Medical  Association,  1897,  p.  419. 
4  Surgical  Complications  of  Typhoid  Fever. 


156     COMPLICATIONS  AND  SEQTJELvE  OF  TYPHOID  FEVER. 

case  recorded  by  Ohlmacher  there  was  found  a  mixed  infection  by 
this  bacillus  and  the  streptococcus. 

Altogether  but  sixteen  cases  of  true  meningeal  infection  by  the 
bacillus  of  Eberth  of  an  undoubted  character  have  been  recorded, 
which  is  a  point  of  great  interest. 

In  all  of  these  the  dura  mater  and  pia  mater  appear  to  be 
equally  affected,  and  the  effusion  was  in  at  least  six  of  the  cases 
purulent. 

Illustrative  cases  of  this  character  are  taken  as  follows  from 
Ohlmacher's  paper  : 

"A  case  of  meningitis  occurring  in  the  course  of  typhoid  fever 
was  described  by  Kamen1  in  1890,  in  a  soldier  who  entered  the 
hospital  after  having  been  ill  for  five  days.  A  severe  headache  set 
in  three  days  later,  followed  by  delirium  and  unconsciousness,  and 
death  occurred  eight  days  after  admission  to  the  hospital.  Aside 
from  acute  splenic  tumor  and  a  single  typhoid  ulcer  near  the  csecal 
junction  of  the  ileum,  the  post-mortem  examination  showed  an 
extensive  purulent  leptomeningitis.  The  cultures  obtained  from 
the  spleen,  mesenteric  glands,  and  meninges  were  identical,  though 
only  the  potato  test  was  mentioned  as  having  been  employed  for 
identification.  The  following  year  Fernet2  reported  the  case  of  a 
woman  who  developed  headache,  delirium,  strabismus,  exophthal- 
mus,  retention  of  urine  and  irregularity  of  the  pupils  in  the  course 
of  typhoid  fever.  At  autopsy  the  characteristic  changes  of 
typhoid  fever  were  found  in  the  abdominal  cavity,  and  a  diffuse 
serous  meningitis  was  also  present.  It  is  claimed  that  typhoid 
bacilli  were  isolated  from  the  meningeal  fluid,  though  no  mention 
is  made  of  special  tests.  Silva3  likewise  observed  at  autopsy  in 
a  female  epileptic,  ten  years  of  age,  a  sero-hemorrhagic  leptomen- 
ingitis with  a  lobar  pneumonia  and  the  ordinary  evidences  of 
typhoid  fever.  Typhoid  bacilli  were  isolated  from  the  meninges 
and  carefully  identified.    Still  another  case  was  reported  by  Honl,4 

1  International  Klin.  Rundschau,  1890,  vol.  iv.  No.  3,  p.  98 ;  No.  4,  p.  156. 

2  Le  Bulletin  Medical,  1891,  p.  653. 

3  Riforma  Medica,  1891,  vol.  iii.  No.  210. 

4  Centralblatt  fiir  Bacteriologie,  1893,  Bd.  xiv.  p.  767. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  157 

who  found  a  diffuse  purulent  leptomeningitis  in  a  twenty -one- 
year-old  woman,  who  died  in  the  course  of  typhoid  fever.  An 
exhaustive  differential  examination  showed  the  only  bacterial  spe- 
cies obtained  from  the  meningeal  exudate  to  be  bacillus  typhosus. 

"  Cases  essentially  similar  to  those  just  noted  have  been  reported 
since  1892  by  Vincent,1  Hintze,2  Mensi  and  Carbone,3  Stuhlen,4 
Tietine,5  Kuhnau/'  and  a  second  one  by  Kamen." 

"  Tictine  reported  two  cases  which  came  under  his  observation, 
and  he  also  produced  a  purulent  meningitis  in  animals  by  means 
of  subdural  inoculations  with  typhoid  cultures.  The  second  one 
of  his  cases  differs  from  all  others  in  that  the  patient  was  per- 
fectly conscious  during  the  last  week  of  his  life. 

"  Profound  unconsciousness,  delirium,  coma,  and  often  reten- 
tion of  urine  are  the  symptoms  most  often  described  in  these  cases. 
Other  symptoms  which  might  suggest  an  actual  meningitis  are 
usually  insignificant,  and  can  scarcely  be  looked  upon  as  of  diag- 
nostic import.  To  this  rule,  however,  the  case  mentioned  by 
Mensi  and  Carbone  is  a  notable  exception.  Their  patient  was  a 
girl  six  years  of  age,  who  had  been  ill  nine  days  before  entering 
the  hospital.  The  patient  ran  the  course  of  a  moderate  attack  of 
typhoid  fever,  reaching  the  stage  of  apyrexia  four  weeks  after 
coming  to  the  hospital.  Four  days  later  a  violent  chill  occurred, 
with  intense  headache  and  a  temperature  of  39.2°  C.  Delirium, 
opisthotonus,  contractions,  amblyopia,  and  dilated  non-responsive 
pupils  were  successively  noted,  together  with  a  herpes  labialis, 
paresis  of  right  face,  and  retraction  of  abdominal  wall.  Great 
prostration  followed,  and  death  occurred  four  days  after  the  onset 
of  this  relapse.  The  autopsy  showed  a  fibrino-purulent  cerebro- 
spinal meningitis,  with  dilatation  of  the  lateral  ventricles,  and  a 
bronchitis  of  the  medium  and   smaller  bronchioles.     Numerous 

1  Schmidt's  Jahrhucher,  1893,  Bd.  ccxxxvii.  No.  2. 

2  Centralblatt  fur  Bacteriologie,  1893,  Bd.  xiv.  No.  14. 
;i  Ri forma  Medica,  1893,  vol.  i.  p.  14. 

4  Berliner  klin.  Wochenschrift,  1894,  No.  15. 

'  Archives  de  Med.  Experiment,  1894,  tome  vi.  p.  1. 

fi  Berliner  klin.  Wochenschrift,  1896,  No.  2"\ 

7  Centralblatt  fur  Bacteriologie,   1st  ahthcilunic,  1897,  Bd.  xxi.  Nos.  11-12. 


158     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

typical  typhoid  ulcers  in  the  stage  of  healing  were  found  in  the 
ileum  and  colon ;  the  mesenteric  glands  were  swollen  and  soft, 
and  there  was  softening  of  the  spleen.  A  thorough  bacterio- 
logical examination  of  the  meningeal  exudate  resulted  in  finding 
typhoid  bacilli  as  the  sole  bacterial  inhabitant." 

In  rare  cases  where  death  has  occurred  from  meningitis  without 
enteric  fever  being  suspected,  the  autopsy  has  revealed  the  bacillus 
of  Eberth  to  be  its  cause,  as  has  been  reported  by  Curschman. 
Such  instances  have  been  recorded  by  Ohlmacher  and  are  of  in- 
terest.    He  tells  us  that : 

"  In  the  course  of  a  study  of  meningitis,  Neumann  and  Schaef- 
fer1  (1887)  found  an  extensive  purulent  leptomeningitis  in  a 
woman  brought  to  the  hospital  unconscious,  and  who  died  in  a 
few  hours  without  furnishing  any  history.  No  lesions  of  typhoid 
fever  were  found,  but  pure  cultures  of  a  bacillus  were  obtained 
from  the  meninges,  and  these,  the  authors  were  led  to  believe, 
were  of  bacillus  typhosus,  from  the  general  character  and  from 
the  positive  results  of  the  potato  and  fermentation  differential 
tests.  A  very  similar  case  was  reported  soon  after  by  Adenot,2 
in  which  a  woman  presented  profound  symptoms  of  cerebral  infec- 
tion and  died  in  eight  days.  Absolutely  no  typhoidal  lesions  were 
present  in  the  intestines,  spleen,  and  mesenteric  glands,  but  from 
the  sero-purulent  exudate  in  the  soft  meninges  a  bacillus  resem- 
bling the  typhoid  organism  was  obtained.  The  only  differential 
test  here  applied  was  the  growth  on  potato,  and  we  now  know 
that  this  is  not  sufficient  to  identify  the  bacillus  of  typhoid  fever. 
The  case  recorded  by  Balp3  also  belongs  in  the  same  category  with 
those  of  the  authors  just  noted.  He  found  a  diffuse  purulent  men- 
ingitis in  a  patient  dying  five  days  after  a  fracture  of  the  skull, 
and  in  the  exudate  a  bacillus  resembling  the  Eberth  organism  was 
found,  together  with  a  species  of  diplococcus.  The  phenol  and 
indol  tests  are  all  that  Balp  mentions  having  used  for  differeDtia- 
tion." 

1  Virchow's  Archives,  1887,  Band.  cix.  Heft.  3,  p.  477. 

2  Archives  de  Med.  Experiment  et  d'Anat.  Pathol.,  1889,  tome  i.  p.  656. 

3  Eivista  Generale  Ital.  et  de  Chir.  Med.,  1890,  No.  17,  p.  406. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  159 

A  case  of  purulent  cerebro-spinal  meningitis  complicating 
typhoid  fever  has  also  been  reported  by  Stuhlen.1  The  patient 
was  a  man  whose  wife  and  children  were  also  sufferers  from 
typhoid  fever.  He  first  suffered  from  wretchedness,  headache, 
chills,  and  constipation.  When  admitted  to  the  hospital,  four 
days  later,  there  was  stupor,  restlessness,  and  delirium,  and  on 
the  fifth  day  sudden  collapse,  from  which  he  rallied,  but  persist- 
ent stupor  remained.  On  the  seventh  day  there  was  rigidity  of 
the  neck  and  slight  jaundice.  An  examination  of  the  cerebro- 
spinal pus  showed  the  typhoid  bacillus. 

Very  recently  Kerr  and  Moffitt2  reported  to  the  California 
Academy  of  Medicine  the  case  of  a  man  of  twenty-eight  years, 
who  on  admission  was  found  in  a  stupid  mental  state  when  he 
had  been  ill  for  a  period  of  three  or  four  weeks.  He  had  been 
seized  with  general  weakness,  fever,  loss  of  appetite,  headache, 
and  pain  in  the  right  iliac  region,  no  cough  or  nose-bleed.  The 
cause  of  his  entrance  to  the  hospital  was  the  pain  in  the  right  iliac 
region,  weakness,  and  headache.  He  was  found  to  be  slightly 
demented,  and  answered  questions  slowly,  articulating  poorly,  but 
there  was  no  real  aphasia.  The  fever  ran  an  erratic  course,  resem- 
bling tubercular  meningitis  more  closely  than  typhoid  fever.  The 
pulse  was  fairly  slow  and  dicrotic.  There  were  no  spots  and  no 
eye-symptoms ;  there  was  persistent  diarrhoea  of  the  pea-soup 
variety,  and  rapid  emaciation  ;  the  Widal  test  was  obtained,  and 
autopsy  showed  a  few  old  ulcers  in  the  right  ileum  which  were  cer- 
tainly six  or  eight  weeks  old  ;  the  brain  was  covered  with  a  thick 
purulent  exudate,  yellow-red  in  color.  Cultures  were  made  which 
showed  mobile  bacilli  giving  the  negative  glucose  test,  but  clump- 
ing with  typhoid  serum. 

Boden3  reports  the  case  of  a  fourteen-year-old  child  who  suf- 
fered from  typhoid  fever  and  was  admitted  to  the  Augusta  Hos- 
pital of  Cologne,  on  October  2d,  at  about  the  end  of  the  first  week 
of  the  disease.     There  was  hyperesthesia  of  the  entire  body,  and 

1  Berliner  klin.  Wochenschrift,  April  9,  1894 

2  Journal  of  the  American  Medical  Association,  March  18,  1899 

:;  Miincheher  Medicinische  Wochenschrift  for  February  2S,  1899. 


160     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

cyanosis.  Two  days  later  there  was  a  severe  epileptic  attack  and 
deep  stupor,  with  left-sided  abducens  and  facial  paralysis,  with 
loss  of  pupillary  reflex  and  the  patellar  reflex.  Death  occurred 
three  days  later,  and  the  autopsy  revealed  marked  typhoid  fever 
of  the  first  week,  and  meningitis  serosa,  a  large  amount  of  clear 
serum  being  present  at  the  base  of  the  brain.  The  brain  was 
normal,  the  ventricles  were  distended.  From  the  fluid  in  the 
ventricles  a  pure  culture  of  the  bacillus  of  Eberth  was  obtained  ; 
this  fluid  also  gave  the  Widal  test.  Boden  states  that  only  five 
cases  of  this  character  have  been  reported,  namely,  those  of 
Stuhlen,  Kuguan,  Daddi,  Hintz,  and  Honl. 

The  frequency  of  this  complication  wheu  due  to  true  typhoid 
infection  of  the  meninges  in  the  different  periods  of  the  disease  is 
in  direct  ratio  to  the  length  of  the  malady,  namely,  in  the  third 
or  fourth  week,  and  in  the  great  majority  of  instances  in  which 
the  complication  has  appeared  the  patient  was  under  thirty  years, 
and  usually  between  twenty  and  thirty  years,  the  period  in  which 
typhoid  fever  is  most  commonly  seen. 

In  every  case  of  true  typhoid  meningitis,  so  far  as  recorded, 
death  has  occurred,  but  this  is  a  statement  which  does  not  possess 
as  great  prognostic  value  as  would  appear  at  first  glance,  since 
an  absolute  diagnosis  of  true  typhoid  meningitis  cannot  be  made 
during  life,  for  the  positive  test  is  the  bacteriological  examination 
of  the  skull  contents.  Nevertheless,  the  presence  of  marked 
meningeal  symptoms  is  of  the  gravest  import  in  all  cases. 

Sometimes,  because  of  degenerative  changes  in  the  vessels,  a 
hemorrhagic  effusion  into  the  meninges  of  the  brain  takes  place, 
but  this  does  not  commonly  produce  marked  symptoms  unless  it  is 
profuse. 

Cerebral  Thrombosis  and  Embolism.  Richardson1  has 
recorded  a  case  of  a  man  of  forty -three  years,  who  in  the  third 
week  of  the  disease  suffered  from  intense  headache,  chiefly  in  the 
left  temporal  region,  accompanied  by  collapse  and  a  subnormal 
temperature.      He  rallied  under  stimulating  treatment,   but  two 

1  Journal  of  Nervous  aud  Mental  Diseases. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  161 

days  later  there  was  marked  coma,  contracted  pupils,  particularly 
that  on  the  right  side.  Convulsive  movements  were  also  present 
on  the  left  side,  chiefly  in  the  leg.  Later  the  right  side  of  the 
body  was  involved.  He  died  five  days  after  this  complication 
arose,  and  the  autopsy  revealed  no  signs  of  meningitis,  but  the 
veins  of  the  pia  mater  were  distended  with  five  clots,  one  of  which 
was  particularly  large  and  lay  along  the  Rolandic  fissure.  The 
sinuses  were  patulous.  In  the  first  left  temporal  convolution 
there  was  a  small  abscess.  No  clots  were  found  in  the  sinuses. 
There  are  three  interesting  points  in  this  case  :  First,  the  develop- 
ment of  convulsions  of  a  more  or  less  localized  character  in  the 
course  of  typhoid  fever ;  second,  the  fact  that  there  was  general 
thrombosis  of  the  intracranial  veins  without  the  sinuses  being- 
involved,  and,  third,  the  entire  absence  of  any  signs  of  meningitis 
at  the  autopsy,  although  the  symptoms  during  life  seemed  to  indi- 
cate the  presence  of  this  condition.  This  last  fact  is  of  particular 
interest  in  view  of  the  fact  worthy  of  recollection,  as  already 
pointed  out,  that  while  meningeal  symptoms  may  be  well  marked 
in  enteric  fever,  true  meningitis  is  comparatively  rare. 

When  it  is  remembered  that  thrombosis  of  the  cerebral  sinuses 
is  the  usual  lesion,  and  that  such  an  authority  as  Gowers1  ques- 
tions whether  primary  venous  thrombosis  ever  occurs  without 
sinus  thrombosis,  and  that  Macewen,2  in  his  classical  work  on  the 
surgery  of  the  brain  and  cord,  says  nothing  of  marantic  primary 
venous  thrombosis,  the  rarity  of  this  condition  is  noteworthy. 
Hirt3  says  it  may  occur  in  the  veins  as  well  as  the  sinuses,  but 
Dana,4  Rosenthal,5  Gray,6  and  Brill7  fail  to  describe  it. 

We  may  call  attention  to  the  fact  that  thrombosis  of  the  cerebral 
sinuses  is  usually  said  to  be  due  to  an  exhausting  disease  or  to 
infection.  In  such  a  case  as  that  just  described  both  these  factors 
were  present. 

Finally,  it  is  interesting  to  note  that  an  additional  factor  in 
this  case  still  further  complicated  the  clinical  diagnosis,  namely,  a 

1   Diseases  of  the  Nervous  System.  2  Ibid. 

3  Ibid,  4  Ibid.  ■>  Ibid.  G  II. id. 

7  Article  in  Dercum's  Diseases  of  the  Nervous  system. 

11 


162     COMPLICATIONS  AXD  SEQUEL  JS  OF  TYPHOID  FEVER. 

history  that  the  patient  had  had  two  severe  head  injuries,  one 
twelve  years  before  and  one  two  months  before. 

A  case  of  evident  thrombosis  recently  occurred  in  my  wards  in 
the  person  of  a  student  of  twenty  years.  He  came  under  obser- 
vation on  the  third  day  of  his  illness,  and  for  the  next  eleven  days 
passed  through  a  marked  but  moderate  attack  of  typhoid  fever. 
On  the  fifteenth  day  of  the  disease  he  was  suddenly  seized  with 
hurried  stertorous  breathing,  rising  from  26  to  48  respirations  a 
minute,  and  his  pulse  rose  from  the  neighborhood  of  116  to  148, 
and  finally  to  160.  He  developed  hemiplegia  of  the  right  side, 
unconsciousness,  contracted  pupils,  and  the  eyeballs  were  deviated 
upward.  Both  pulmonary  bases  posteriorly  filled  up  rapidly, 
becoming  dull  on  percussion  and  developing  coarse  rales.  The 
skin  became  cyanotic,  and  blood-stained  mucus  was  expelled  from 
the  mouth  by  the  stormy  respirations.  He  died  about  ten  hours 
after  these  symptoms  began,  with  marked  retraction  of  the  head 
and  neck.  Xo  autopsy  was  permitted,  but  from  the  symptoms  I 
am  inclined  to  regard  the  condition  as  due  to  embolus  or  throm- 
bus in  the  lung  causing  infarction,  and  in  the  cerebral  vessels 
causing  the  paralytic  and  other  nervous  symptoms. 

Lopriore1  has  reported  a  case  of  typhoid  fever  in  a  little  girl  of 
ten  years,  in  which  on  the  seventeenth  day  of  the  disease  the 
patient  developed  aphasia  and  great  restlessness ;  the  child  could 
understand  what  was  said  to  it,  and  there  was  no  paralysis  of  any 
of  its  limbs ;  the  motor  aphasia,  however,  lasted  for  a  period  of  a 
month  and  a  half,  when  the  child  was  gradually  taught  to  speak 
again.  Lopriore  believes  that  this  case  was  due  to  a  microbic 
embolus,  which  plugged  a  branch  of  the  Sylvian  artery  and 
thereby  influenced  the  Broca  centre. 

Convulsions,  generalized  or  local,  with  coma  and  delirium  may 
arise  from  thrombosis  of  the  cerebral  sinuses  or  of  the  cerebral 
arteries,  but  they  are  very  rare  from  any  cause  (see  hemiplegia 
article  for  cases).  Murchison  only  met  with  them  in  six  cases  out 
of  2960  cases.     If  due  to  the  lesions  named,  they  indicate  a  fatal 

1  Gazzetta  degli  ospedali  e  delle  cliniche,  January  5,  1899,  p.  25. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  163 

termination  in  the  near  future.  In  Osier's  case  death  followed 
convulsions  produced  l>v  thrombosis  of  the  branches  of  the  left 
middle  cerebral  artery  in  twelve  hours.  If  they  occur  in  neurotic 
children  or  females  the  outlook  is  not  so  gloomy,  as  they  probably 
do  not  depend  upon  an  actual  lesion  in  the  brain.  Thus  West  has 
recorded  a  ease  in  which  convulsions  developed  in  the  third  week 
of  typhoid  fever  in  a  child,  recurring  on  two  successive  days. 
These  were  followed  by  hemiplegia  which,  however,  gradually 
disappeared  in  four  days.      Recovery  eventually  took  place. 

During  February,  1899, 1  saw  in  consultation  with  Dr.  Loux,  of 
Philadelphia,  a  girl  in  the  third  week  of  typhoid  fever  with  typical 
hysteria,  as  shown  in  the  facial  expression  and  in  the  attitude  of 
her  body.  Her  arms  were  abducted,  her  forearms  completely 
flexed  at  a  right  angle  with  the  arms,  and  the  hands  completely 
flexed  at  a  right  angle  with  her  forearms.  This  case  showed, 
nevertheless,  evidences  of  profound  toxaemia,  and  died  a  few  days 
later.  When  first  taken  ill  she  was  very  hysterical,  cried  and 
screamed,  and  repeatedly  asserted  if  she  got  typhoid  fever  she 
would  die. 

A  possible  cause  of  sudden  death  during  typhoid  fever,  or  in 
convalescence,  is  said  to  be  bulbar  paralysis.  Thus  Latil1  men- 
tions a  woman  of  forty-two  years,  who  suffered  from  a  severe 
attack  of  typhoid  fever  with  hyperpyrexia  and  extreme  pros- 
tration, but  not  equally  marked  nervous  symptoms.  On  the 
eighteenth  day  of  the  attack  she  suffered  from  paralysis  of  the 
bladder,  and  on  the  forty-second  day  from  tetanic  contraction  of 
the  masseter  muscles,  with  dysphagia  and  a  nasal  voice.  The 
respiration  became  shallow  and  rapid,  the  patient  seemed  greatly 
oppressed,  had  an  anxious  face,  and  asphyxia  so  rapidly  increased 
that  death  occurred  in  a  few  hours.  It  seems  to  me  that  there  is 
grave  doubt  whether  this  case  was  not  one  of  peripheral  nerve 
paralysis  rather  than  a  central  lesion,  but  that  sudden  death  may 
occur  from  a  small    lesion  occurring  in  the  medulla  is  illustrated 

1  Revue  G^n^rale  de  Clinique  et  de  Th^rapeutique,  March,  21,  1890, 


164     COMPLICATIONS  AND  SEQUEL JE  OF  TYPHOID  FEVER. 

by  a  case  which  has  been  reported  by  Libouroux,1  in  "which  sud- 
den death  occurred  during  the  third  week  of  the  disease,  and  an 
autopsy  revealed  a  small  hemorrhage  in  the  floor  of  the  fourth 
ventricle.  There  was  no  other  condition  which  could  account  for 
the  sudden  death  of  the  patient. 

Stiffness  of  certain  muscles  isolated  or  in  groups  is  also  met 
with,  and  may  sometimes  resemble  that  seen  in  lateral  sclerosis  of 
the  cord. 

Iso  less  authorities  than  Hughlings  Jackson  and  Angel  Money 
have  stated  that  knee-jerks  are  never  lost  in  enteric  fever.  This 
is  scarcely  correct,  for  I  have  recently  seen  a  case,  not  excessively 
ill,  in  which  they  were  absent  for  days  at  a  time  as  completely  as 
in  ataxia  or  some  cases  of  diabetes. 

Restlessness  and  insomnia,  often  complained  of  by  the  patient, 
is  much  more  rare  than  the  complaints  would  indicate.  Watchful 
nurses  will  report  repeatedly  and  truthfully  that  such  patients 
sleep  the  greater  part  of  the  night  and  day,  and  the  lack  of  sleep 
is  either  a  delusion  or  else  the  few  waking  moments  seem  pro- 
longed into  hours  to  the  patient.  On  the  other  hand,  persistent 
insomnia  marked  by  unnatural  cjuiet,  the  patient  lying  with  the 
eyes  closed,  may  lead  the  careless  attendant  to  report  prolonged 
sleep,  when  in  reality  true  sleeplessness  is  present.  When  insom- 
nia is  due  to  feeble  circulation,  the  use  of  alcohol  stimulation  will 
usually  relieve  the  condition,  and  morphine  may  be  useful. 

We  come,  then,  to  the  consideration  of  subsultus  tendinum  and 
carphologia.  Both  of  these  are  signs  of  grave  illness,  particu- 
larly the  latter,  but  they  are  neither  of  them  as  mortal  in  their 
prognostic  import  as  the  older  authors  thought,  for  patients  with 
these  symptoms  often  get  well. 

Under  the  name  of  "  irritation  of  the  brain  with  depression  of 
temperature,"  a  condition  has  been  described  by  Liebermeister, 
which  comes  on  in  about  the  second  week  of  the  disease  when  the 
symptoms  are  most  violent,  and  in  patients  who  have  had  pro- 
longed high  temperature.     The  pupils  lose  their  reaction  to  light, 

1  Gazette  Hebdomadaire  de  Medecine  et  de  Chirurgie,  March  5,  1890. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  165 

and  symptoms  of  meningeal  irritation  develop,  or  in  their  place 
marked  mental  changes  occur,  the  patient  becoming  maniacal  or 
deeply  melancholic.  More  noteworthy  than  all,  the  temperature 
suddenly  falls  almost  to  normal,  and  remains  there  for  several 
days,  as  long  as  the  symptoms  named  continue,  when  it  rises  again 
to  the  points  usually  met  with  at  that  period  of  the  malady,  and 
proceeds  as  before.  Such  cases  are  very  rare.  In  his  enormous 
experience,  Liebermeister  only  met  with  "  eight  or  ten  cases." 

Tyson  asserts  that  in  cases  of  typhoid  fever  in  which  the  patient 
also  suffers  from  epilepsy,  the  epileptic  attacks  are  apt  to  be 
greatly  multiplied  in  the  early  periods  of  the  disease  ;  to  cease  as 
the  disease  progresses,  and  to  remain  absent  till  convalescence  is 
established. 

Neuritis  may  come  on  in  typhoid  fever  in  the  latter  part  of  the 
third  week  or  in  the  fourth  week,  but  it  is  generally  a  complica- 
tion noted  during  convalescence.     (See  chapter  on  convalescence.) 

Almost,  if  not  equally  rarely,  pain  in  the  muscles  is  developed 
as  the  result  of  a  myostitis. 

Paralysis  arising  from  typhoid  fever  usually  comes  on  during 
the  very  latest  stage  of  the  disease  or  in  convalescence,  and  is  so 
distinctly  an  after-symptom,  as  a  rule,  that  it  will  be  considered 
under  the  division  in  which  the  late  complications  and  sequelae 
are  discussed.  Rarely,  however,  as  will  be  pointed  out,  the  loss 
of  power  may  occur  in  the  middle  of  the  febrile  attack. 

As  an  evidence  of  the  rarity  of  extensive  and  permanent  paral- 
ysis of  the  extremities  complicating  or  following  typhoid  fever, 
I  may  quote  the  statement  of  Alexander  who,  during  an  experi- 
ence of  ten  vears  and  a  half  in  the  medical  clinical  at  Breslau, 
did  not  meet  with  a  single  case  of  paralysis  among  3900  typhoid 
patients.  (Hemiplegia  in  typhoid  fever  is  discussed  later  on  in 
the  volume.) 

The  Skin  in  the  Well-developed  Stage  of  the  Disease.  The 
rash  of  typhoid,  which  usually  develops  about  the  seventh  or 
ninth  day,  is  usually  characterized  by  its  rose-spot  appearance.  A 
delicate  pink  hyperemia  of  the  skin  is  all  that  it  amounts  to  in 
many  cases,  and  the  rash  may  be  so  sparse  as  only  to  be  found  by 


166     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

the  most  careful  examination  of  the  whole  body,  when  a  few  spots 
will  reward  the  search.  They  are  usually  found  on  the  belly,  the 
chest,  or  the  back.  In  other  cases  the  spots  are  very  profuse,  being 
present  literally  by  the  hundred.  This  is  rare.  During  the  past 
year  the  writer  has  been  impressed  by  the  fact  that  the  rash  has 
been  unusually  profuse  and  exceedingly  coarse.  The  individual 
spots  have  been  not  only  large  and  well-defined,  but  distinctly 
elevated  and  maculo-papular  to  an  extraordinary  extent.  Further, 
in  these  cases  repeated  crops  of  this  roseola  have  repeatedly  ap- 
peared as  the  disease  progressed.  The  rose  rash  of  enteric  fever, 
however,  is  so  typically  separated  as  to  its  various  spots,  and  there 
is  so  little  coalescence,  that  few  of  the  general  forms  of  rose  rash 
resemble  it. 

In  rare  instances,  however,  the  rash  does  coalesce,  and  then  may 
resemble  measles,  and  in  still  other  cases  where  its  papular  form 
is  lacking,  this  coalescence  may  render  it  very  much  like  that  of 
scarlet  fever.  If  the  case  is  enteric  fever  the  abdominal  symp- 
toms point  to  that  cause  of  the  rash,  while  on  the  other  hand,  if 
it  is  scarlet  fever  the  throat  symptoms  will  point  to  this  malady. 
In  those  cases  in  which  marked  pharyngeal  irritation  ushers  in 
typhoid  fever,  however,  the  diagnosis  may  be  very  difficult. 
Recently  a  patient  under  my  care  suffered  from  a  mild  attack  of 
typhoid  fever  lasting  seventeen  days,  and  ten  days  later  was  sud- 
denly seized  by  a  high  temperature  and  general  illness.  When 
he  came  under  observation  a  second  time  he  had  a  profuse  rash 
over  his  body ;  his  eyes  were  injected,  and  on  the  mucous  mem- 
brane of  the  palate  and  on  the  roof  of  the  mouth  there  was  a 
profuse  punctated  eruption.  The  subsequent  course  of  this  case 
showed  that  he  was  suffering  from  a  mild  typhoid  relapse.1 

The  rash  of  typhoid  fever  is  not  a  constant  symptom,  and  may 
appear  on  the  arms  and  even  the  hands,  instead  of  on  the  trunk. 
In  199  cases  under  Osier  13.1  per  cent,  had  no  rash. 

Abnormal  eruptions  occurring  in  typhoid  fever  in  children  were 

1  For  a  discussion  of  the  various  forms  of  roseolous  rash  see  the  author's  Text- 
book of  Practical  Diagnosis,  fourth  edition,  1 899. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  167 

described  as  long  ago  as  1839  by  Taupiu,1  who  tells  us  that  a 
uniform  erythema  resembling  scarlet  fever  may  be  present,  but 
is  not  followed  by  desquamation  or  oedema.  He  also  says2  that 
he  has  never  seen  a  vesicular  rash  such  as  has  been  described 
before  his  time  by  Prosper  Dor. 

The  other  forms  of  aberrant  rash  in  typhoid  fever  are  usually 
developed  later  than  the  tenth  day.  They  consist  in  small  hem- 
orrhagic exudations  or  petechia?.  In  other  cases  they  may  be  as 
large  as  a  silver  half-dollar,  and  do  not  disappear  on  pressure.  It 
is  as  if  the  rash  developed  and  then  hemorrhage  took  place  into 
the  spot. 

Another  form  of  skin  manifestation  in  typhoid  fever  is  the 
tache  bleuatre.  They  were  first  described  as  occurring  in  typhoid 
fever  in  1837  bv  Piedaernel.  I  have  been  confident  that  I  have 
seen  them  in  cases  which  were  not  infected  by  lice,  but  Hewetson3 
speaks  as  follows  in  respect  to  this  question  : 

"  There  exists  a  considerable  difference  of  opinion  as  to  the 
diagnostic  value  of  these  spots.  Many  writers,  particularly  the 
English,  believe  that  they  are  often  seen  in  the  early  stages  of 
typhoid  fever,  and  have  laid  some  stress  upon  their  presence, 
although  they  admit  their  occasional  occurrence  with  pediculi. 
Other  observers,  especially  the  French,  claim  that  they  do  not 
exist  unless  pediculi,  and  more  particularly  the  pediculi  pubis,  are 
present ;  that  when  the  spots  exist  the  pediculi  or  their  nits  can 
be  found  if  looked  for  carefully.  Our  experience  leads  us  to 
believe  that  the  latter  view  is  correct,  as  in  the  cases  of  typhoid 
fever  in  which  the  pcliomata  were  present,  we  were  able  in  each 
instance  to  find  either  the  pediculi  or  their  nits.  There  have  been 
several  cases,  other  than  typhoid  fever  in  which  these  grayish- 
blue  spots  were  found,  but  always  associated  with  pediculi.  There 
are  at  present  two  cases  in  the  wards,  one  with  catarrhal  jaundice 
and  another  admitted  for  chronic  bronchitis  and  emphysema.      In 

1  Journal  des  Connaissances  Med.  ('hirurgieale,  is:}1,). 

2  This  essay  is  an  exhaustive  and  excellent  account  of  the  disease  as  seen  early 
in  this  century. 

3  Johns  Hopkins  Hospital  Bulletin,  vol.  v. 


168     C02IPLICATI0NS  AND  SEQUELS  OF  TYPHOID  FEVER. 

neither  case  is  there  any  elevation  of  temperature,  but  in  both 
there  are  numerous  steel-gray  spots  scattered  over  the  abdomen, 
thorax,  inner  sides  of  the  thighs,  and  here  and  there  on  the  arms 
and  legs.  In  both  the  pediculi  are  numerous,  particularly  over 
the  pubes,  and  also  in  the  hair  over  the  various  sites  where  the 
tache  bleuatre  are  present.  In  both  cases  they  are  quite  plenti- 
ful in  the  axilla?,  but  in  neither  have  they  been  found  on  the  hairs 
of  the  head  or  face.  They  do  not  appear  to  have  caused  much 
irritation ;  neither  patient  complained  of  itching,  nor  are  there 
marks  of  much  scratching.  Indeed,  I  find  that  one  patient,  for- 
merly an  Austrian  soldier,  is  quite  indignant  at  the  removal  of 
both  hair  and  pediculi.  He  tells  me  that  they  are  considered  as 
bringing  luck  to  the  bearer,  and  each  sells  for  from  five  to  ten 
kreuzers  among  the  soldiers.  They  have  been  carefully  carried 
by  him  for  ten  years." 

Sudamina,  due  to  the  retention  of  sweat  drops  beneath  the  epi- 
thelial layer  of  the  skin,  are  met  with  in  cases  in  which  sweating 
has  taken  place,  during  high  fever,  as  a  rule.  It  is  claimed  by 
Baradat  de  Lacaze  that  sudamina  may  possess  definite  prognostic 
value.  In  quite  an  exhaustive  paper1  he  concludes  that  the  ap- 
pearance of  sudamina  at  the  beginning  of  the  second  week  of 
typhoid  fever  are  of  little  or  no  value  in  fixing  the  prognosis  ;  but, 
on  the  other  hand,  their  appearance  again  in  the  second  week,  or  in 
the  period  of  ambiguity,  nearly  always  indicates  the  entrance  into 
active  convalescence.  De  Lacaza  believes  its  development  at  this 
time  means  a  crisis  in  the  course  of  the  affection. 

Urticaria  may  occur,  and  there  may  also  be  a  peculiar  mottling 
of  the  skin  due  to  local  capillary  atony. 

The  so-called  tache  cerelorale  is  a  red  line  with  white  borders, 
produced  in  this  and  other  fevers  by  drawing  the  finger-nail  over 
the  skin  of  the  patient. 

Deeper  lesions  of  the  skin  than  those  just  discussed  sometimes 
complicate  typhoid  fever.  They  consist  in  boils  and  carbuncles, 
and  are  due  to  infection  of  the  follicles  by  pyogenic  organisms  of 

1  Revue  de  Mediein,  1887,  p.  275. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE. 


169 


the  ordinary  forms  or  by  the  specific  organism  of  enteric  fever. 
They  are  usually  met  with  in  cases  which  are  severe  and  charac- 
terized by  great  lowering  of  the  vitality,  and  are  probably  more 
often  met  with  in  convalescence  than  in  the  acute  period  of  the 
fever.  The  writer  suffered  from  a  carbuncle  on  the  back,  which 
came  on  about  the  twelfth  day  of  an  attack  and  persisted  during 
a  relapse  and  well  into  the  second  convalescence. 

Bed-sores  usually  develop  only  in  those  cases  which  are  pro- 
foundly ill,  or  are  not  well  nursed,  in  the  sense  that  they  lie  in 
bedding  which  is  soiled  by  discharges.  Since  the  use  of  the  cold 
bath  or  sponging  they  are  rarely  met  with,  because  this  method  of 
treatment  causes  the  patient  to  change  his  posture  frequently, 
keeps  him  clean,  and  restores  the  local  circulation  in  the  skin 
where  it  is  anaemic  or  congested.  The  most  common  seat  for  this 
lesion  to  occur  is  over  the  sacrum. 

Superficial  gangrene  of  the  skin  is  very  rare,  but  was  met  with 
very  early  in  the  history  of  the  recognized  disease.  Thus  Taupin1 
mentions  a  case  of  sloughing  of  the  thighs,  sacral  region,  knees, 

Fig.  16. 


Superficial  gangrene  of  the  skin  occurring  in  author's  wards. 

elbows,  and  of  the  face,  in  a  child  with  typhoid  fever.  The  skin 
became  violaceous  in  appearance  and  mortified,  and  this  was 
accompanied  by  increase  in  the  delirium.  In  one  case  under  my 
care  at  the  present  time  it  developed  on  the  inside  of  the  left  calf 


1  Journal  des  Connaissances  Med.  Chirurgicale,  1839,  No. 


170     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

of  a  girl  of  nineteen  years,  who  had  suffered  some  days  before 
from  a  series  of  profuse  hemorrhages,  for  which  hypodermoclysis 
had  to  be  used  to  save  life.  None  of  the  areas  of  injection 
sloughed,  and  no  injection  was  given  near  this  spot,  which  broke 
down.  (See  Fig.  16.)  Two  brown  ecchymotic  spots  formed 
on  the  heels  where  they  rested  on  the  bed,  but  did  not  slough. 
The  separation  of  the  slough  was  accompanied  by  loss  of  power 
and  sensation  in  the  anterior  part  of  the  leg,  evidently  from  periph- 
eral neuritis.1  (For  further  discussion  of  this  subject,  see  the 
circulation  in  the  developed  stage  of  typhoid  fever,  and  nervous 
lesions  in  convalescence.) 

Herpes  labialis  is  thought  by  some  to  exclude  the  diagnosis 
of  enteric  fever  if  it  be  present.  Osier  reports  two  cases  in  which 
it  occurred,  2and  the  writer  has  seen  one  during  the  present  year. 

That  herpes  occurs  quite  frequently  in  some  epidemics  of 
typhoid  fever  is  shown  by  the  statement  of  Zinn,3  who  states  that 
it  was  met  with  in  5  per  cent,  of  190  cases  in  the  hospital  at 
Nuremberg. 

A  very  extraordinary  series  of  cases  of  gangrene  of  the  skin 
has  been  recorded  by  Stahl,  which  occurred  in  soldiers  in  St. 
Agnes'  Hospital  in  1898.  He  has  kindly  permitted  me  to  use 
the  following  figures.  (See  Plates  I.  and  II.) 

Taupin4  states  that  he  saw  two  children  die  in  typhoid  fever 
with  severe  erythema  nodosum,  and  that  sudamina  were  common 
in  his  experience. 

Hemorrhagic  eruptions  may  occur  in  the  course  of  typhoid 
fever,  and,  as  a  rule,  they  appear  in  the  neighborhood  of  the 
joints,  when  the  exudation  may  be  small  or  quite  large. 

Nichols5  reports  four  cases  in  which  the  hemorrhagic  diathesis 
developed  on  the  thirteenth,  eighteenth,  twenty-eighth,  and  thirty  - 

1  For  an  interesting  paper  on  infectious  disseminated  gangrene  of  the  skin,  see 
Caillaud  in  the  Revue  Mensuelle  des  Maladies  de  l'Enfance,  1897,  p.  1. 

2  Johns  Hopkins  Hospital  Reports,  1895,  vol.  v. 

3  Miinchener  Med.  Wochenschrift. 

4  Journal  des  Connaissances  Med.  Chirurgicale,  1839,  No.  7. 

5  Montreal  Medical  Journal,  June,  1896. 


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WELL-DEVELOPED  STAGE  OF  THE  DISEASE.         171 

sixth  days  of  typhoid  fever.  Only  one  of  these  cases  died.  Very 
rarely  the  tendency  to  hemorrhagic  leaking*  may  become  general 
and  result  in  haemoptysis,  hsematemesis,  and  hemorrhages  from 
the  bowels.  A  case  of  this  character  is  recorded  in  the  North 
( 'arolina  Medical  Journal  for  September,  1890,  in  which  a  child 
of  ten  years  suffered  from  this  disease.  At  the  end  of  the  fourth 
week  of  the  disease  there  was  bleeding  from  the  gums,  the  nose, 
and  blood  in  the  urine.  The  spots  appeared  first  on  the  feet  and 
legs,  later  on  the  arms,  then  on  the  trunk,  and,  finally,  in  the 
conjunctiva. 

In  other  cases  hemorrhages  other  than  those  just  named  took 
place.  Thus  Hughes  and  Levy1  report  a  case  in  which  a  man, 
after  an  ordinary  attack  of  typhoid  fever,  suffered  from  a  relapse 
in  the  sixth  week.  Abscesses  developed  in  both  forearms  and  in 
the  left  arm.  When  an  incision  was  made  into  the  abscess  extra- 
vasations of  blood  into  the  intramuscular  aponeurotic  tissues  took 
place,  and  afterward  this  was  followed  by  manifestations  of  acute 
purpura,  as  indicated  by  petechias,  ecchymoses  and  severe  epistaxis. 
Recovery  took  place. 

Another  abnormality  in  the  typhoid  rash  has  been  described  by 
Day.2  The  eruption  was  on  the  chest,  abdomen,  and  back,  and 
occurred  in  irregular  dark  patches,  slightly  raised,  and  disappeared 
on  pressure,  though  they  left  some  pigmentation  after  their  dis- 
appearance. They  were  not  petechias.  Day  asserts  that  he  has 
met  with  ten  other  cases  of  this  character,  and  further,  that  in 
four  of  them  intestinal  hemorrhage  was  foretold  by  their  occur- 
rence in  connection  with  fever,  a  rapid  pulse,  and  a  clear  mind. 

Eruptive  Diseases  in  the  Course  of  Typhoid  Fever.  How 
frequently  scarlet  fever  complicates  typhoid  fever  is  a  difficult 
fact  to  decide.  Murchison3  says  that  in  ten  years  he  saw  only 
one  case  of  scarlet  fever  which  contracted  typhoid  fever,  and 
that  ensued  on  the  twenty-sixth  day.  On  the  other  hand,  he  cites 
several  cases  in  which  typhoid   fever  patients  suffered  later  from 

1  Archives  de  M<5decine  et  de  Pliar.  Militaires,  August,  1  s*. cj. 

2  Dublin  Journal  of  Medical  Sciences,  March,  1806. 

3  British  and  Foreign  Medico-Chirurgical  Review,  July  1859,  p.  194. 


172     COMPLICATIONS  AND  SEQTJELJE  OF  TYPHOID  FEVER. 

scarlet  fever.  This  was  written  in  1859.  Later  still  he  wrote1 
that  in  the  wards  of  the  London  Fever  Hospital,  in  which  all 
fever  cases  were  treated  without  isolaton,  he  had  seen  eight  cases  in 
which  the  eruption  of  the  two  diseases  existed  simultaneously. 
In  one  of  these  the  eruption  of  scarlet  fever  appeared  in  the  third 
week  of  enteric  fever,  and  in  the  other  on  the  twenty-second  day. 
Indeed,  he  goes  so  far  in  one  place2  as  to  assert  that  scarlet  fever 
appears  to  predispose  to  typhoid  fever. 

Sequeira3  records  two  cases  of  typhoid  fever  complicated  by 
scarlet  fever.  In  one  the  scarlatinal  symptoms  developed  on  the 
tenth  day,  and  in  one  five  days  after  the  enteric  rash.  Still  more 
interesting  are  the  cases  recorded  by  Griffiths.4  Four  children, 
all  in  the  same  family,  were  attacked  by  both  diseases.  A  boy  of 
eleven  years  on  the  sixth  day  of  scarlet  fever  developed  typhoid 
fever.  A  girl  of  thirteen  years  got  scarlet  fever  three  weeks  after 
her  brother  and  enteric  fever  twelve  days  later.  A  girl  of  three 
years,  who  had  scarlet  fever,  suffered  from  typhoid  fever  on  the 
eleventh  day,  and  a  girl  of  seven  years  also  on  the  eleventh  day 
after  scarlet  fever  began.  These  cases  are  of  special  interest  in 
that  a  nearly  simultaneous  infection  with  both  fevers  must  have 
occurred. 

Caiger5  met  with  two  cases  of  scarlet  fever  coincident  with 
typhoid  fever,  and  Payne6  reports  one  such  case. 

Carmichael7  also  has  reported  the  case  of  a  boy  of  six  years, 
who,  after  suffering  from  scarlet  fever  and  going  on  to  the  stage  of 
desquamation,  continued  febrile  from  oncoming  typhoid  fever,  and 
Cosgrove8  records  five  cases  of  concurrent  scarlet  and  typhoid 
fever  seen  in  the  Cork  Street  Hospital.  In  four  of  these  the 
incubation  stages  were  concurrent,  the  scarlet  fever  being  second- 
ary, so  that  the  onset  was  simultaneous.  This  same  author  tells 
us  that   instead  of    increasing   the   severity  of    the    typhoid  the 

1  The  Continued  Fevers  of  Great  Britain,  third  edition,  p.  586. 

2  Loc.  cit.,  p.  455.  3  British  Medical  Journal,  1891.  vol.  i.  p.  849. 
*  Lancet,  1893,  vol.  ii.  p.  1307.  5  Lancet,  1894,  vol.  i.  p.  1137. 
6  Ibid.  7  Ibid.,  p.  246. 

8  British  Medical  Journal,  January  16,  1897,  p.  29. 


WELL-DEVELOPED  STAGE  OF  THE  DISEASE.  173 

scarlet  fever  seemed  to  abort  it,  though  the  cases  were  fairly 
severely  ill.  Coombs1  reports  a  case  in  which  a  boy  of  eleven 
years,  who  had  scarlet  fever,  his  family  having  typhoid  fever,  was 
seized  on  the  seventeenth  day  of  his  illness  by  typhoid  fever. 
Gabe2  reports  another  ease. 

The  danger  of  confusing  adventitious  scarlatiniform  rash  in 
typhoid  fever  with  that  of  scarlet  fever  was  emphasized  by  Mur- 
chison  and  by  Moore3  and  Jenner,4  and  more  recently  by  Bassett.5 
Moore  has  also  seen  desquamation  take  place  in  this  form  of  rash.6 

A  case  of  a  child  of  eleven  and  a  half  years  has  been  reported 
by  Chrystie,7  which  is  of  particular  interest,  because  of  the  fact 
that  measles  developed  during  the  attack  of  typoid  fever.  Death 
occurred  in  convulsions.  A  similarly  constituted  attack  of  typhoid 
fever  and  measles  is  also  recorded  by  Matiegka.8  The  symptoms 
of  enteric  fever  were  well  marked  on  the  fourteenth  day  of  the 
disease,  when  the  eruption  of  measles  appeared  over  the  face  and 
body.  A  similar  case  has  been  reported  by  Ringer,9  in  a  girl  of 
ten  years,  and  Ringwood,10  records  a  case  in  which  the  child  had 
measles  and  enteric  fever  simultaneously,  followed  by  a  severe 
attack  of  diphtheria,  scarlet  fever,  and  chicken-pox,  all  in  the 
space  of  seven  weeks. 

1  British  Medical  Journal,  February  27,  1897 

2  Loc.  cit.,  April  3,  1897,  p.  848. 

3  Accidental  Rashes  in  Typhoid  Fever,  Transactions  Royal  Academy  of  Medi- 
cine in  Ireland,  1889,  vol.  vii.  p.  10,  and  Eruptive  and  Continued  Fevers,  1892, 
p.  371. 

4  Fevers,  1893.  5  British  Medical  Journal,  April! 0,  1897. 

6  Loc.  cit.,  January  16,  1897. 

7  University  Medical  Magazine,  December,  1888. 

8  Prager  Med.  Wochenschrift,  September  25,  18S9. 

9  London  Lancet,  June  30,  1889.      10  Loc.  cit.  July  7,  1889. 


CHAPTER    IV. 

THE  COMPLICATIONS  OF  THE  PERIOD  OF  CONVALESCENCE. 

Temperature,  Recrudescence,  and  Relapse.  Recrudescence 
signifies  a  temporary  rise  of  fever  lasting  for  a  few  days  or  a  few 
hours,  and  is  usually  due  to  the  ingestion  of  improper  food,  to  ner- 
vous excitement,  or,  more  rarely,  it  seems  to  arise  from  absorption 
from  the  intestinal  canal  of  some  toxic  material  which  temporarily 
upsets  the  balance  of  heat-production  and  heat-dissipation.  In 
two  instances  I  have  seen  full  doses  of  strychnine,  given  as  a  cir- 
culatory stimulant,  produce  repeated  exacerbations  of  the  normal 
temperature  to  the  extent  of  two  or  three  degrees  by  reason  of  its 
irritant  effect  on  the  nervous  system. 

As  has  already  been  said,  a  true  relapse  cannot  be  said  to  have 
taken  place  until  the  physician  is  assured  by  another  crop  of  rose 
rash,  enlargement  of  the  spleen,  coated  tongue,  and  persistent  fever 
that  a  second  attack  is  upon  the  patient.  If  these  distinct  signs  of 
another  infection  are  present,  then  the  diagnosis  is  complete. 

Relapses  occur  in  a  fairly  large  percentage  of  cases,  and  seem 
particularly  prone  to  take  place  in  those  in  whom  the  primary 
attack  of  the  malady  has  been  mild.  Indeed,  the  milder  the 
attack,  the  more  likelihood  is  there  of  relapse.  Further  than  this, 
the  use  of  the  cold  bath  in  treating  the  disease  increases  the  fre- 
quency of  relapse  quite  distinctly.  Wnat  the  average  frequency 
of  this  unfortunate  occurrence  is  is  difficult  to  determine,  because 
different  epidemics  differ  greatly  in  the  results  they  produce,  so 
that  in  one  epidemic  relapses  will  occur  with  great  constancy,  and 
in  another  almost  none  will  occur.  Ord1  believes  that  relapses 
are  more  frequent  in  cases  with  constipation  than  in  those  with 

1  Transactions  of  Association  of  American  Physicians,  1888,  vol.  iii. 


COMPLICATIONS  DURING  CONVALESCENCE.  175 

diarrhoea,  and  that  reinfection  from  within  explains  their  fre- 
quency in  these  instances.  In  the  writer's  experience,  relapses 
have  been  much  more  common  in  constipated  cases. 

In  regard  to  the  frequency  of  relapse  it  is  interesting  to  note  that 
no  less  an  observer  than  Murchison  places  the  average  percentage 
at  3  per  cent. ;  Gerhardt,  in  4000  cases,  6.3  per  cent. ;  Griesinger 
puts  it  at  6  per  cent.,  and  Striimpel  at  4  to  16  per  cent.  Berg1  met 
with  relapse  in  12  per  cent,  of  1626  cases  in  Curschman's  clinic  from 
1880  to  1892.  Eichhorst,  in  666  cases  in  Zurich,  found  relapses 
in  4.2  per  cent.  Zennetz2  in  384  cases  of  typhoid  fever  found  47 
relapses,  of  which  17  were  entirely  uncomplicated.  In  the  Maid- 
stone epidemic  relapses  occurred  in  16  per  cent.,  and  were  more 
common  in  females  than  in  males.  Schmidt3  found  49  cases  of 
relapse  in  561  cases  of  fever  treated  in  Wagner's  clinic  from  1882 
to  1886,  or,  if  doubtful  cases  be  excluded,  38  relapses,  or  a  per- 
centage of  6.8  per  cent.,  which  practically  agrees  with  the  percent- 
age obtained  by  Gerhardt,  who  in  the  study  of  4000  cases  selected 
from  various  epidemics,  obtained  a  percentage  of  6.3  per  cent., 
while  Heman's  percentage  was  6.5,  and  Steinthal's,  7.5  per  cent. 
Liebermeister  says  :  "  In  Basel,  before  the  introduction  of  this  (the 
bath)  treatment,  861  typhoid  fever  patients  gave  us  64  relapses,  or 
7.4  per  cent.,  two  of  which  were  fatal ;  after  the  introduction  of  this 
treatment,  882  typhoid  fever  patients  gave  86  relapses,  or  9.8  per 
cent.,  ten  of  which  proved  fatal.  It  appears,  therefore  that  the 
proportion  of  relapses  and  the  number  of  deaths  are  both  actually 
increased  under  the  use  of  cold  water."  And  discussing  the  prob- 
able bearing  of  these  results,  he  adds  :  "At  present  the  probability 
certainly  seems  to  be  in  favor  of  the  affirmative  of  the  question 
(does  bathing  increase  the  frequency  of  relapses '?)  the  more  so  as 
it  appears  that  the  frequency  of  relapses  is  greater  in  proportion 
as  the  antipyretic  treatment  has  been  the  more  systematically  cm- 
ployed."  Biermer  has  also  found  relapses  more  frequent  since 
the  introduction  of  cold  baths.     Osier  met  with  1  4  cases  of  relapse 

1  Deutsche  Archiv  fur  klin.  Med.,  1895. 
-'  Wiener  med.  Wochenschrift,  September  21,  1894. 
Archiv.  fur  klin.  Medicin,  Band  xliii.  I  left.  3. 


176     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

in  160  cases  bathed,  or  8.7  per  cent.,  but  mentions  five  other  cases 
of  doubtful  relapses,  which  raises  the  percentage ;  while  Shattuck 
met  with  21  in  129  cases,  or  16  per  cent.,  and  eleven  occurred 
before  primary  fever  ceased.  Wilson  tells  us  that  it  occurred  in 
11.3  per  cent,  of  his  cases,  and  Osier  tells  us  8.7  per  cent.;  Shat- 
tuck, 16  per  cent. ;  Immermann,  15  to  18  per  cent.;  Baumler,  11 
per  cent. ;  and  Jaccoud,  9  per  cent.,  varying  from  7  to  15  per 
cent.  At  the  Presbyterian  Hospital  in  New  York  Gilman  Thomp- 
son found  the  relapses  in  193  bathed  cases  to  be  13.5  per  cent., 
which  is  2  per  cent,  higher  than  284  cases  treated  by  all  methods 
during  the  same  time. 

There  are  certain  peculiarities  in  the  course  of  a  relapse  as  to 
the  fever,  the  circulation,  and  the  other  functions  which  deserve 
attention.  The  fever  usually  rises  more  abruptly  than  in  the  orig- 
inal attack,  and  then  speedily  loses  its  high  grade  and  becomes 
more  moderate.  Often  it  is  more  irregular  and  has  greater  remis- 
sions than  the  primary  fever.  Whether  it  be  high  or  low,  its  course 
is  usually  shorter  than  the  original  period  if  that  has  been  of  stand- 
ard length  or  longer,  while  if  it  has  been  quite  short  the  relapse  is 
not  infrequently  much  longer.  Thus  in  one  case  recently  seen  by 
the  writer,  the  primary  fever  lasted  twelve  days,  and  that  of  relapse 
nineteen  days.  Flint  is  the  only  author  of  note  who  thinks  the 
relapse  is  generally  worse  than  the  primary  attack. 

It  is  interesting  to  note  that  in  Liebermeister's  cases  out  of  111 
cases  of  simple  relapse  the  fever  was  longer  in  duration  than  in 
the  first  attack  in  37,  shorter  in  68,  and  of  the  same  length  in  2. 
In  29  of  the  cases  the  primary  attack  was  mild,  and  in  82  severe, 
but  the  relapses  were  mild  in  47  and  severe  in  64,  and  7  of  these 
died  in  the  relapse. 

An  important  point  to  determine  is  the  danger  of  relapse  both 
as  to  complications  and  mortality.  Here,  again,  the  variation  in  the 
severity  of  the  symptoms  in  relapse  is  so  great  that  it  is  almost 
impossible  to  reach  definite  results.  It  is  certain  that  relapses  are 
not  to  be  regarded  lightly,  and  that  they  should  be  recognized 
with  a  certain  degree  of  anxiety,  even  when  they  appear  to  be 
mild  in  type,  because  the  exhausted  state  of  the  patient  renders 


COMPLICATIONS  DURING  CONVALESCENCE.  177 

him  more  prone  to  complications  and  less  able  to  withstand  the 
general  toxaemia  of  the  new  infection. 

This  is  well  shown  by  the  statistics  at  Basel,  when  out  of  115 
relapses  hemorrhage  from  the  bowel  occurred  four  times,  perfora- 
tion twice,  thrombosis  once,  pulmonary  consolidation  nine  times, 
nose-bleed  seven  times,  bed-sores  four  times,  abscesses  five  times, 
and  petechia?  three  times. 

To  quote  Liebermeister  again  :  "If  we  take  the  reports  of  the 
years  1869,  1870,  and  1872  at  Basel,  we  find  among  467  typhoid 
fever  patients  systematically  treated  with  cold  baths,  33  deaths 
and  55  relapses,  6  of  which  were  fatal ;  the  frequency  of  relapses, 
therefore,  counting  only  those  patients  who  had  survived  the  first 
attack,  was  in  the  proportion  of  12.5  per  cent.,  as  against  9  per 
cent,  before  baths  were  used.  The  higher  rate  of  mortality  among 
the  relapses  is  of  so  much  greater  import,  in  view  of  the  fact  that 
the  relapses,  too,  were  treated  antipyretically,  which  ought  rather 
to  have  given  us  a  lower  death-rate." 

The  time  at  which  relapses  occur  is  of  interest.  Usually  they 
take  place  after  the  temperature  has  been  normal  several  days,  but 
in  some  instances  much  later  than  this.  More  rarely  we  meet 
with  what  has  been  well  called  "  intercurrent  relapse,"  in  which 
the  renewed  activity  of  febrile  movement  and  exacerbations  of  all 
the  symptoms  show  that  a  second  infection  has  been  superimposed 
on  the  first. 

In  children  relapses  are,  as  a  rule,  more  rarely  met  with  than 
in  adults,  although  this  accident  varies  greatly  in  frequency. 
Among  the  older  writers  we  find  Rilliet  and  Barthez,  who  saw 
only  three  relapses  in  111  patients,  while  on  the  other  hand, 
Henoch  met  with  no  less  than  21  relapses  in  137  cases,  the 
relapses  taking  place  after  both  severe  and  mild  primary  attacks, 
although  the  mild  attacks  were  most  commonly  productive  of  this 
accident.  Taupin,  writing  in  1839,  records  two  cases  of  relapse 
in  boys  of  thirteen  and  twelve  years ;  both  recovered. 

As  with  adults,  the  relapse  usually  takes  place  in  children  in 
from  three  to  ten  days  after  primary  fever  has  ceased,  although 
it   may  occur  in  the  course  of  the  disease  in   the  third  week,  or 

12 


178     COMPLICATIONS  AND  SEQUELM  OF  TYPHOID  FEVER. 


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180     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

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Case  of  typhoid  fever  in  which,  according  to  the  patient's  story,  he  had  been 
sick  only  three  days,  but  in  which  the  disease  ended  by  a  rapid  fall  in  lysis,  fol- 
lowed by  a  severe  rigor  and  rise  of  temperature.  The  Widal  test  was  positive, 
and  the  rash  and  enlarged  spleen  were  present. 

Not  only  may  a  patient  suffer  from  a  single  relapse,  but  rarely 
from  several  relapses.  Hutchinson1  has  recorded  a  case  in  which 
three  well-marked  relapses  occurred,  and  Anders2  has  done  so  also. 

The  chart  (Fig.  17)  shows  two  relapses. 

1  American  System  of  Medicine,  Pepper,  vol.  i.  p.  303. 

2  Medical  and  Surgical  Reporter,  July,  1882,  p.  66. 


COMPLICATIONS  DURING  CONVALESCENCE.  181 

Multiple  relapses  have  also  been  recorded  by  Johnston.1  In 
one  case  a  patient  of  thirty -nine  years  had  two  relapses,  and  was 
in  the  hospital  eighty-one  days.  A  second  case  had  two  relapses. 
A  third  case  after  a  primary  attack  had  two  relapses,  and  the 
patient  was  in  the  hospital  107  days. 

A  case  of  typhoid  fever  is  recorded  by  Carslaw,2  which  suf- 
ered  from  four  relapses  before  ultimate  recovery ;  and  I  have 
now  under  my  care  a  case  in  his  third  relapse. 

Rigors  of  considerable  severity  may  occur  during  convalescence 
from  typhoid  fever  without  possessing  any  great  significance. 
This  is  shown  in  the  chart  on  page  178,  and  also  in  that  on  page 
180  (Fig.  18). 

Similar  cases  are  recorded  by  Herringham.  Thus  he  records 
an  instance  in  which  after  a  mild  attack  of  fever  a  rigor  occurred 
during  the  post-febrile  period  after  an  enema ;  another  case  in 
which  there  were  several  attacks  of  pyrexia  and  one  rigor  during 
this  time,  and  still  a  third,  in  which  recurrent  collapse  appeared 
during  lysis,  and  rigors  in  the  post-febrile  period  Avithout  any  dis- 
coverable cause.  He  believes  that  ague  can  be  excluded  in  all  of 
his  cases.  Herringham  also  advances  the  view  that  in  these  cases 
the  heat  mechanism  of  the  body  is  so  easily  upset  that  very  slight 
causes  provoke  febrile  movement,  and  in  this  view  the  writer  con- 
curs. Osier  reports  two  cases  of  chills  without  any  distinct  appar- 
ent cause  in  the  later  weeks  of  typhoid  fever.  In  both  these  cases 
the  chills  were  followed  by  hyperpyrexia. 

Some  years  ago  Da  Costa  pointed  out  that  during  convalescence 
from  typhoid  fever  a  persistent  moderate  fever  may  develop,  which 
is  cured  by  getting  the  patient  out  of  bed.  Shattuck  also  speaks 
of  such  cases.  I  have  had  under  my  care  several  instances  of  this 
character.  The  getting  up  ought  not  to  be  made  till  it  is  evident 
that  the  fever  is  simply  a  "bed  fever"  and  not  a  relapse1. 

Respiratory  Affections  in  the  Convalescent  Stage  of  the 
Disease.  Aside  from  the  laryngeal  (sec  earlier  and  later  pages) 
and  other  respiratory  difficulties  met  with  in  the  active  stage  of 

1   Medical  Chronicle,  May,  1892.  -  London  Lancet,  July  19,  1891. 


182      COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER. 

the  disease,  there  are  no  others  to  be  considered  at  this  point  save 
pulmonary  abscess,  gangrene,  and  tuberculosis.  The  latter  condi- 
tion will  be  discussed  in  a  later  chapter  dealing  with  the  diseases 
which  ape  enteric  fever. 

Abscess  and  gangrene  of  the  lung  are  rare  sequences  of  enteric 
fever.  They  arise  from  one  of  two  causes  :  either  they  are  due  to 
septic  matter  which  has  passed  into  the  bronchial  tubes  during  the 
stage  of  stupor,  or  to  septic  emboli  which  first  cause  consoli- 
dation and  then  tissue  break-down.  Griesinger  met  with  gangrene 
of  the  lung  in  seven  cases  out  of  118  post-mortems,  and  Lieber- 
meister  found  fourteen  cases  in  230  autopsies  of  typhoid  fever 
patients. 

The  question  as  to  whether  typhoid  fever  predisposes  the  patient 
to  infection  by  the  bacillus  of  tuberculosis  is  one  of  great  interest. 
Cases  convalescing  from  typhoid  fever  are  sometimes  met  with  in 
which  tuberculosis  is  rapidly  developing.  In  some  instances  this 
is  due  to  the  fact  that  the  profound  depression  of  the  patient's 
vitality  renders  him  unusually  susceptible  to  any  infectious  pro- 
cess, but  more  frequently  it  is  probably  due  to  the  fact  that  the 
patient  has  had  at  some  previous  time  a  localized  tubercular  pro- 
cess which  has  been  walled  off  from  the  general  system  by  the 
usual  methods  taken  by  the  body  for  its  protection.  With  the 
progress  of  a  prolonged  exhausting  malady  vital  resistance  has  de- 
creased, and  the  local  and  comparatively  harmless  process  rapidly 
spreads  throughout  the  body. 

In  connection  with  this  matter  it  is  interesting  to  note  that 
Loison  and  Simonin,1  in  114  typhoid  fever  cadavers,  found  tuber- 
culosis five  times,  and  they  point  out  that  typhoid  fever  may 
hasten  the  development  of  pre-existing  tubercular  infection.  So, 
too,  Sarda  and  Villard2  have  found  the  diseases  coexisting. 

Zinn3  states  that  post-mortem  examination  of  the  fatal 
cases  in  190  patients  revealed  the  fact  that  six  of  them  showed 

1  Archives  de  Medecine  et  de  Pharmacie  Milita're,  Paris,  October,  1893. 

2  Gazette  des  Hopitaux,  November  30,  1893. 

3  Munchener  med.  Wochenschrift. 


COMPLICA  TIONS  D  URING  CONVA LESCENCE.  183 

tuberculosis  of  the  lung  in  association  with  old  foci  at  the 
apex. 

In  cases  of  typhoid  fever  which  are  convalescent  the  presence 
of  irregular  and  prolonged  febrile  movement  should  raise  a  sus- 
picion of  the  presence  of  pulmonary  tuberculosis. 

The  Circulation  in  the  Later  Stages  of  the  Disease  and  in 
Convalescence.  There  are  few,  if  any,  diseases  which  do  not 
have  special  predilection  for  the  heart  muscle  or  its  valves  which 
so  gravely  interfere  with  proper  circulation  as  does  typhoid  fever. 
The  length  of  the  febrile  movement  and  its  severity,  the  gravity 
of  the  toxaemia,  the  wasting  of  the  patient,  his  inability  in  certain 
cases  to  take  sufficient  nourishment,  and  the  impaired  action  of 
various  other  vital  organs  than  the  heart,  all  tend  to  produce 
weakness  in  the  heart  muscle  and  actual  degenerative  changes  in 
its  nerve-supply  and  fibres.  As  long  ago  as  1875  Hayem3  made 
one  of  his  characteristically  thorough  studies  concerning  the  heart 
muscle  in  typhoid  fever,  in  which  he  showed  that  a  granular 
parenchymatous  degeneration  is  present  in  many  cases,  and  that 
even  fatty  degeneration  may  be  met  with  in  prolonged  severe  cases 
associated  with  great  ameniia.  Hyaline  changes  are  not  commonly 
found,  but  a  segmenting  myocarditis,  in  which  the  intercellular 
cement  substance  is  softened  may  be  present,  although  this  is,  per- 
haps, a  post-mortem  change.  Many  years  ago  Stokes  asserted  that 
the  heart  muscle  of  patients  dead  of  enteric  fever  was  so  softened 
that  if  it  were  held  upside  down  by  its  great  vessels  the  muscle 
would  collapse  over  the  hand  like  a  mushroom  overspreads  its 
stem.  In  some  cases,  on  the  other  hand,  the  heart  seems  to  escape 
almost  completely. 

As  it  is  not  the  intent  of  this  essay  to  deal  with  the  microscopical 
alterations  which  occur,  but  rather  the  objective  symptoms  of  the 
disease,  little  further  need  be  said  of  these  changes  themselves, 
except  that  in  this  connection  the  researches  of  Hoffmann  are  of 

1  Lecons  Cliniqne  sur  les  Manifestations  Cardiaques  et  le  Fi&vre  Typhoide, 
Paris,  1875. 


184     COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER. 

interest.  He  found  in  an  examination  of  a  large  number  of  hearts 
in  typhoid  fever  patients  56  instances  in  which  the  heart  muscle 
was  normal  or  little  changed ;  39  in  which  it  was  slightly  granu- 
lar, the  striations  still  being  visible  ;  46  in  which  the  muscle  was 
granular ;  1 9  in  which  it  was  slightly  waxy ;  1  in  which  was 
granular  degeneration,  and  1  in  which  it  was  very  waxy. 

It  is  worthy  of  note  that  these  changes  are  responsible  in  a 
large  proportion  of  cases  for  the  sudden  deaths  which  occur  in  the 
convalescent  period  of  the  disease,  even  more  commonly  than  in 
the  course  of  the  disease  itself.  So  frequent  is  this  condition  of 
sudden  cardiac  failure  an  accident  of  convalescence  rather  than 
of  the  febrile  attack,  that  Graves  tells  us  that  even  if  the  fever 
has  departed  and  everything  about  the  patient  is  favorable,  we 
are  not  justified  in  banishing  all  anxiety  or  in  relaxing  vigilance, 
as  a  sudden  effort  on  the  part  of  the  patient  may  cause  fatal  syn- 
cope. Instances  of  this  sort  have  been  recorded  among  the  older 
writers  by  Bailly,  Graves,1  Jaccoud,  and  Louis.  More  recently 
Dewerve2  reports  that  in  48  cases  analyzed  by  him  the  heart 
was  found  softened,  pale,  and  of  a"  dead-leaf  color "  in  fifteen 
instances  ;  had  undergone  fatty  or  granular  degeneration  in  six- 
teen instances,  and  in  three  others  there  was  proliferative  endar- 
teritis of  the  small  vessels  of  the  heart. 

Dewerve  also  found  in  analyzing  these  cases  that  it  occurred 
most  frequently  in  persons  between  the  ages  of  twenty-two  and 
twenty-five  years,  probably  because  this  is  the  age  most  frequently 
affected  by  enteric  fever,  and  that  old  age  and  infancy  rarely  suf- 
fered from  it.  The  accident  itself  is  far  more  common  in  men 
than  in  women,  for  this  writer  found  it  in  the  proportion  of 
114  to  26. 

It  is  interesting  to  note  that  this  condition  is  not  a  sequel  of 
severe  cases  alone,  for  Dewerve  asserts,  on  the  contrary,  that  it  is 
emphatically  a  sequel  of  a  moderate  form  of  the  fever  [forme  moy- 
enne).     Further,  violent  effort  is  not  necessary  to  produce  it,  for 

1  Clinical  Medicine. 

2  De  la  Mort  Subite  dans  le  Fievre  Typhoide,  Arch.  Gen.  de  Med.,  1887  vol. 
ii.  p.  385. 


COMPLICATIONS  DURING  CONVALESCENCE.  185 

it  has  occurred  after  so  slight  a  movement  as  extending  the  arm, 
by  emotion,  and  may  develop  without  any  such  cause,  the  patient 
being  found  dead  in  bed  in  the  posture  they  were  in  when  asleep. 
Liebermeister  records  the  case  of  a  woman  who  ate  a  hearty  dinner 
after  convalescence  from  a  mild  illness  of  typhoid  fever.  She 
then  rose  to  go  to  the  closet,  fell  in  a  faint  and  died  in  ten  min- 
utes, and  another  case  of  a  man  who  was  unable  to  take  the 
upright  posture  for  many  weeks  without  suffering  from  nausea, 
vomiting,  collapse,  and  partial  syncope,  but  who  ultimately  recov- 
ered. The  autopsy  in  the  case  of  the  woman  revealed  no  lesions 
save  profound  cerebral  anaemia. 

(For  sudden  death  due  to  nervous  lesions,  see  chapter  on 
developed  stage  of  the  disease,  nervous  symptoms.) 

There  are,  however,  other  causes  of  sudden  failure  of  the  heart 
than  myocardial  degeneration,  namely,  embolism  or  thrombosis  of 
the  coronary  artery  or  arteries,  heart-clot,  thrombosis  or  embolism 
of  the  cavse  or  pulmonary  veins,  and  pericarditis  with  effusion 
which,  pressing  on  the  heart  when  a  change  in  position  is 
attempted,  causes  sudden  death.  In  the  cases  already  quoted  as 
having  been  analyzed  by  Dewerve  (48  cases),  there  were  eight 
with  thrombosis  of  the  coronary  arteries.  In  eight  other  cases 
ante-mortem  clots  were  found  in  the  right  ventricle.  Liebermeis- 
ter reports  one  case  at  Tubingen,  in  which  death  occurred  as  a 
result  of  embolism  of  that  branch  of  the  pulmonary  artery  that 
goes  to  the  lower  lobe  of  the  right  lung.  In  this  case  the  embolus 
arose  from  thrombosis  of  the  right  crural  vein,  and  was  accompa- 
nied by  extensive  hemorrhagic  infarction.  Clots  in  the  coronary 
arteries  may  arise  from  within  the  heart  cavities  from  granulations  on 
the  endocardium.  Further  than  this,  Beaumanoir,1  Fritz,2  Vallette,3 
Forgues,'  Drewitt,5  and  others  have  met  with  these  formations. 

1  La  Progres  Medicale,  1891,  vol.  ix.  p.  364. 

2  Charite  Annalen,  vol.  vi.  p.  169. 

3  Contribution  a  1' Etude  de  la  Gangrene  des  Membres  Pendant  la  Cours  de 
Fievre  Typhoide,  These  de  Paris,  1890,  Ferrand. 

4  Rec.  de  Mem.  de  Med.  Militaire,  1880,  3d  series,  vol.  xxxvi.  p.  386. 
3  Lancet,  1890,  vol.  ii.  p.  1023. 


186     COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER. 

According  to  Drewitt,  however,  these  clots  are  formed  in  the 
the  heart  in  the  acnte  period  of  the  disease,  and  then  are  dislodged 
when  the  circulation  increases  in  tone  during  convalescence.  Viti1 
has  found  the  bacillus  of  Eberth  in  the  granulations  of  endocarditis, 
and,  furthermore,  has  produced  these  lesions  in  rabbits  by  inocu- 
lating them  with  the  bacillus,  and  Vincent2  has  recorded  the  case 
of  a  previously  healthy  soldier,  who  died  from  enteric  fever,  and 
in  the  vegetations  of  his  mitral  valves  these  specific  bacilli  were 
found.  Girode3  has  made  a  similar  report.  Hayem,4  also,  has 
recorded  a  case  in  which  endocardial  difficulty  was  recognized  in 
life,  and  two  days  later  symptoms  of  plugging  of  the  arteries  in 
both  legs  ensued.  First  pulsation  ceased  in  the  dorsales  pedes, 
then  in  the  popliteals,  and  finally  in  the  femorals,  and  gangrene 
developed.  An  embolus  was  found  in  the  femoral  artery,  but  did 
not  extend  below  the  knee.  The  autopsy  showed  ante-mortem 
cardiac  clots,  endocarditis,  thrombosis  of  the  aorta,  and  multiple 
infarctions  in  the  kidney.  On  the  other  hand,  it  must  not  be  for- 
gotten that  endocarditis  complicating  typhoid  fever  is  rare.  Osier 
says  he  has  seen  only  two  cases.  Only  eleven  cases  occurred  in 
2000  cases  in  Munich.  Pericarditis  is  also  very  rare  (14  in  2000 
cases  in  Munich). 

Liebermeister  tells  us  that  endocarditis  is  rare  in  typhoid  fever, 
and  mentions  but  one  case  of  the  severe  form,  accompanied  by  a 
development  of  excessive  warty  growths  with  perforation  of  two 
of  the  semilunar  folds,  and  consequent  infarction  of  the  kidneys 
and  spleen,  double  pleural  pneumonia  and  death.  He  believes, 
however,  that  a  mild  form  of  endocarditis  without  ulceration  is 
more  commonly  met  with. 

In  other  cases  embolism  of  the  pulmonary  artery  results  from 
thrombosis  of  the  femoral  vein  and  causes  sudden  death.     Thus 

1  Atta  della  Roy.  Accad.  del  Fisiocritia  de  Siena,  4th  series,  vol.  ii.  fasc.  5  and 
6,  1890. 

2  Merc.  Medicale,  February  17,  1892,  p.  73. 

3  Comptes  Rendu  Soc.  Biol.,  1889,  p.  622. 

4  Progres  Medicale,  1875. 


COMPLICATIONS  DURING  CONVALESCENCE.  187 

Xawercke1  records  a  case  of  this  character  iu  which  the  patient 
dropped  dead  when  at  stool,  death  coming  on  in  ten  minutes,  and 
Bouley2  reports  a  case  of  ascending  thrombosis  of  the  femoral  veins 
into  the  cava  and  from  there  into  the  right  auricle. 

In  other  instances  an  endarteritis  may  involve  the  coronary 
vessels  and  cause  sudden  death,  if  we  can  rely  upon  the  views  of 
Laudouzy  and  Siredey.3  These  investigators  tell  us  that  from  the 
clinical  point  of  view  the  manifestations  of  cardio-vascular  disease 
in  typhoid  fever  may  present  two  different  aspects.  Sometimes 
the  rapid  spread  of  the  lesions  in  the  heart  and  vessels  is  accom- 
panied by  a  rapid  pulse,  with  great  feebleness  of  the  heart  and, 
perhaps,  by  its  sudden  arrest.  Sometimes,  on  the  contrary,  these 
changes  are  developed  so  slowly  and  insidiously  that  death  occurs 
more  or  less  remotely  and  with  variable  degrees  of  cardiopathic 
change.  The  symptoms  usually  met  with  in  the  first  variety  may 
be  classed  as  those  of  collapse,  with  great  lack  of  power  in  the 
cardiac  muscle.  The  pulse  becomes  extremely  rapid,  small, 
irregular ;  the  face  is  livid,  the  eyes  sunken,  the  voice  feeble,  and 
the  extremities  cold.  The  temperature  may  be  subnormal.  The 
urine  is  scanty  or  suppressed.  The  respirations  are  embarrassed, 
and  the  lungs  are  affected  by  hypostatic  congestion.  Finally, 
coma  and  death  come  on.  This  form  of  collapse  may  come  on  as 
early  as  the  second  or  third  week.  The  feeble  apex  beat  and 
rapid  pulse  indicate  a  diffuse  alteration  in  the  heart  muscle,  which 
is  usually  a  fatty  degeneration  of  its  fibre  (granulo-graisseuse). 
In  cases  of  sudden  death,  on  the  other  hand,  the  lesions  are  chiefly 
connected  with  the  walls  of  the  cardiac  vessels,  the  symptoms  being 
in  abeyance  for  the  most  part  till  the  fatal  moment,  but  dependent 
upon  gradually  increasing  degenerative  processes. 

In  other  cases  where  the  changes  are  less  marked,  the  patient 

1  Correspondenzblatt  fiir  Schweizer  Aertze,  1879,  485. 

2  Progres  M<?dicale,  1880,  viii.  998 

3  Contribution  a  l'Histore  de  l'Artc'rite  Typhoidique,  Rev.  de  Medicine,  1885. 
Those  interested  should  also  read  a  paper  by  Landouzy  and  Siredey,  Etude 
des  Angio-Cardiaques  Typhoidiques  Leurs  Consequences  Immediates,  Prochaine 
et  Eloigners.     Revue  de  MeU,  1887,  p.  804. 


188     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

does  not  suffer  from  severe  and  alarming  symptoms,  but  instead  of 
these  the  patient  is  affected  by  a  disordered  circulation  and  lack  of 
tone  in  the  heart  and  vessels.  The  chief  signs  of  these  conditions 
are  intermittence  of  the  pulse  and  a  harsh  diastolic  murmur  at  the 
cardiac  base. 

The  cardiac  lesions  in  mild  cases  may  be  entirely  recovered  from 
so  far  as  symptoms  are  concerned,  but  the  actual  lesions  themselves 
often  remain,  and  Landouzy  and  Siredey  record  a  case  in  which  a 
second  attack  of  typhoid  fever  came  on  two  years  after  the  first,  and 
at  the  autopsy  old  and  new  lesions  were  found  in  the  myocar- 
dium. 

As  a  matter  of  fact,  the  cardiac  changes  of  typhoid  fever  are 
closely  allied  to  those  that  are  found  in  cases  affected  by  other 
infectious  diseases  of  a  severe  type. 

Sudden  death  in  typhoid  fever  may  occur  as  early  as  the  tenth 
day.  Mery  reported  such  a  case  to  the  Society  Anatomique  in 
October,  1887.  He  states  that  the  myocardium  did  not  show  any 
histological  changes  and  that  the  patient  had  been  treated  by  the 
Brand  bath.  In  discussing  this  case,  Cornil  spoke  of  the  diffi- 
culty of  discovering  any  satisfactory  cause  for  these  accidents,  and 
referred  to  the  fact  that  some  persons  believed  them  to  be  due  to 
changes  in  the  nervous  ganglion  of  the  heart — a  hypothesis  which 
does  not  permit  of  verification. 

Pericarditis,  as  already  stated,  is  rarely  due  to  typhoid  infec- 
tion, although  it  may  complicate  its  course,  being  produced  by 
another  cause.  Thus  Hutchinson  records  a  case  in  which  a  patient 
convalescing  from  enteric  fever  suffered  from  erysipelas,  then 
from  pleurisy,  and  finally  from  pericarditis.  Surely  this  case  was 
due  rather  to  the  streptococcus  than  to  the  bacillus  of  Eberth. 
Liebermeister  only  saw  four  cases  of  pericarditis,  and  all  recovered. 

Very  rarely  sudden  death  ensues  without  our  being  able  to  find 
any  of  the  causes  given.  Dejerine1  has  recorded  two  such  cases, 
in  which  no  sign  of  cardiac  degeneration  could  be  found.    In  such 

1  Comptes  Rendus  Societe  Biologie,  1885,  p.  769. 


COMPLICA  TIONS  D  URINO  CON  VALESCENCE.  \  8 9 

instances  an  embolism  of  an  artery  supplying  an  important  vital 
spot  in  the  medulla  may  be  the  cause. 

Dieulafoy1  asserts  that  in  such  cases  there  may  be  another  cause 
of  death,  namely,  reflex  irritation  along  the  vagus  from  the  abdom- 
inal cavity,  and  which,  being  transmitted  along  the  efferent 
branches  of  this  nerve,  inhibits  the  heart's  action  and  causes  fatal 
syncope.  In  other  instances  he  thinks  that  the  respiratory  centre 
is  rapidly  affected,  and  that  death  results.  Such  reasoning,  in 
view  of  our  knowledge  of  the  functions  of  the  parts  of  the  ner- 
vous system  just  named,  seems  very  hypothetical. 

Death  due  to  the  causes  enumerated  may  come  on  more  gradu- 
ally than  has  been  intimated  so  far.  Thus  dyspnoea,  irregularity 
of  the  pulse,  a  bruit  de  souffle,  and,  rarely,  partial  syncope,  may 
begin  the  end. 

Passing  from  these  changes  to  those  met  with  in  the  general 
bloodvessels,  we  find  that  marked  inflammatory  processes  often 
affect  these  parts  in  the  course  of  typhoid  fever.  One  of  the  most 
important  studies  made  upon  this  subject  is  that  of  Barie,2  who 
asserts,  as  a  result  of  his  work,  that  both  the  large  and  small  ves- 
sels may  be  affected  by  inflammation,  although  the  vessels  of  the 
lower  extremities  are  the  ones  most  often  and  most  severely 
affected.  Thus  in  twenty-two  out  of  twenty-four  cases  this  was 
true.  It  takes  place  generally  when  the  patient  first  leaves  his 
bed  and  begins  to  move  about.  It  is  just  as  apt  to  follow  mild  as 
severe  attacks,  and  it  occurs  in  two  forms,  namely,  as  an  acute 
obliterating  arteritis  and  as  an  acute  parietal  arteritis.  He 
describes  the  change  as  follows  : 

"  The  first  variety  is  constituted  anatomically  by  an  embryonal 
infiltration  of  the  three  coats,  and  disappearance  of  the  smooth  con- 
dition of  the  intima,  which  becomes  uneven  and  granular.  This 
leads,  as  a  consequence,  to  the  production  of  a  secondary  throm- 
bosis, which  in  course  of  time  becomes  a  dense  gray  mass  adherent 
to  the  parictes  of  the  artery.     Very  often  the  inflammation  of  the 

1  De  la  Mort  Subite  dans  la  Ficvre  Typhoide,  Paris,  1869. 

2  Contribution  a  Nlistoirede  TArteritt'  Aigue  Consecutif  a  la  Fievre Typhoide, 
Revue  de  Medicine,  1883,  p.  1,  and  1884. 


190     COMPLICATIONS  AND  SEQUEL  JE  OF  TYPHOID  FEVER. 

artery  is  accompanied  by  a  certain  amount  of  periarteritis.  If  the 
lumen  of  the  affected  artery  is  completely  obliterated  and  the  col- 
lateral circulation  is  not  quickly  established,  mortification  ensues, 
and  the  limb  assumes  the  appearance  of  dry  gangrene.  In  excep- 
tional cases,  in  consequence  of  the  simultaneous  occurrence  of 
venous  thrombosis  or  of  phlebitis,  moist  gangrene  may  follow  the 
mummifying  variety,  or  substitute  itself  for  it. 

"  The  principal  symptoms  of  obliterating  arteritis  are  as  fol- 
lows :  Acute  pain  occurring  more  or  less  suddenly  and  seated  in 
the  course  of  the  affected  artery,  sometimes  localized  in  a  restricted 
region,  as,  for  instance,  the  thigh,  calf,  or  Scarpia's  triangle,  some- 
times occupying  the  whole  length  of  the  limb,  and  increased  by 
pressure  upon  assuming  the  erect  position  and  by  the  movements 
of  walking ;  diminution  of  the  fulness  and,  finally,  suppression  of 
the  pulsations  of  the  artery  ;  swelling  of  the  limb  without  oedema 
or  redness ;  bluish  mottling  of  the  skin ;  sometimes,  although 
rarely,  purpura ;  diminution  of  the  temperature  of  the  limb  with 
or  without  disturbance  of  sensibility,  such  as  formication  and  par- 
tial ansesthesia,  and,  finally,  the  occurrence  in  the  course  of  the 
artery  of  a  hard  and  tender  cord. 

"  The  parietal  arteritis  is  only  a  variety  of  the  preceding  and 
has,  consequently,  the  same  symptoms  but  in  a  less  degree  of 
development,  except,  of  course,  that  the  hard,  painful  cord  is 
absent.  It  is  said,  however,  that  the  diminution  of  the  pulsations 
of  the  artery  is  occasionally  preceded  by  an  exaggeration  of  their 
amplitude,  and  that  in  a  few  cases  the  temperature  of  the  affected 
limb  has  been  observed  to  be  higher  than  that  of  the  other. 

"  It  must  be  borne  in  mind  that  some  of  the  symptoms  of  the 
obliterating  variety  may  arise  from  an  embolus,  but  the  presence 
of  a  valvular  murmur  and  of  other  signs  of  disease  of  the  heart, 
and  the  suddenness  of  the  seizure,  will  enable  us  to  recognize 
without  difficulty  the  cases  dependent  upon  this  cause. 

"  The  therapeutic  indications  in  the  milder  forms  are  best  ful- 
filled by  rest  in  bed,  the  application  of  emollients  or  soothing 
ointments  to  the  limb  and  wrapping  it  in  cotton.  In  cases  in 
which  gangrene  has  occurred  the  patient  should  be  supported  by 


COMPLICATIONS  DURING  CONVALESCENCE.  191 

tonics  and  a  liberal  diet,  and  appropriate  antiseptic  dressing  should 
be  applied  to  the  part." 

Other  reports  on  this  subject  have  been  made  by  Ferrand,1  Des- 
champs,2  Mettler,3  Quervain,4  and  Haushalter.5 

In  addition  to  these  interesting  researches  there  are  others  of 
even  greater  interest,  as,  for  example,  those  of  Rattone,0  who  in 
four  cases  found  the  bacillus  of  Eberth  in  the  arterial  walls  and 
obtained  pure  cultures  from  this  source.  The  result  of  this  infec- 
tion and  endarteritis  is  to  aid  in  the  formation  of  thrombi,  and 
these  in  turn,  by  plugging  of  the  vessel,  cause  rapid  dry  gangrene 
of  the  tributary  part.     (See  lesions  in  the  skin.) 

The  bacilli  are  supposed  to  reach  the  arterial  wall  by  the  blood- 
stream rarely,  or  by  the  blood-stream  in  the  vasa-vasorum. 

The  veins  are  very  much  more  apt  to  be  affected  by  thrombus 
than  the  arteries,  as  every  one  with  a  large  experience  with  typhoid 
fever  well  knows.  Haushalter  and  Vaques  have  found  the  bacilli 
in  the  walls  of  these  vessels,  and  Rattone  and  Haushalter  have 
found  them  in  the  thrombi  themselves,  and  also  that  the  endothe- 
lium under  the  clot  was  destroyed. 

As  a  result  of  this  thrombosis  with  phlebitis  we  may  have  devel- 
oped phlegmasia  alba  dolens,  but  very  rarely  gangrene  because 
the  collateral  circulation  is  more  free  in  the  veins. 

The  clots  in  the  veins  may  be  single  or  multiple,  and  may  be  of 
very  extraordinary  size.  In  de  Santi's  case7  a  clot  extended  from 
the  vena  cava  in  the  iliac  vein  down  into  the  femoral  vein,  and 
one  extraordinary  case  is  recorded  by  Beaumanoir,8  in  which  clots 
were  in  the  arteries  of  both  legs,  in  the  right  ventricle,  in  the  pul- 
monary artery,  in  the  femoral  veins,  and  in  the  aorta.  Cases  of 
clots  reaching  from  the  femoral  vein  to  the  vena  cava  are  recorded 

1  These  de  Paris,  1890.  2  Ibid.,  1886. 

:i  Philadelphia  Medical  Times,  February  19,  1887,  p.  339,  and  New  York  Medi- 
cal Journal,  March,  1895,  p.  289. 

4  Centralblatt  fur  Innere  Med.,  August  17,  1895,  p.  793. 

5  Mercredi  Medicale,  September  20,  1893,  p.  453. 

6  Delia  Arterite  Tifosa  in  Dehu. 

7  Rec.  Mem.  de  Med.  Milit.,  1879,  series  3,  xxxv.  502. 

8  Progres  Med.,  1891,  ix.  364. 


192     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

by  Duniontpalier,1,  Sorel,2  Bouley,3  and  Mackintosh.4  A  case  of 
thrombosis  of  the  iliac  veins  and  the  lower  part  of  the  ascending 
vena  cava  has  been  reported  by  Pansini5  in  a  case  under  his  care. 
GEderua,  lividity,  pain  and  loss  of  power  in  the  legs  were  present. 
Pansini  refers  to  a  statistical  article  of  Vimont,  who  up  to  1890 
collected  112  cases  from  the  literature  of  this  character. 

A  carious  case  of  varicosity  of  the  subcutaneous  veins  of  the 
trunk  and  extremities  is  reported  by  Mackintosh".  The  veins 
involved  were  the  jugular  and  internal  mammary  and  external 
pudic,  the  superficial  epigastric,  internal  saphenous,  and  superfi- 
cial circumflex  on  both  sides.  It  is  supposed  by  the  reporter  that 
a  thrombus  formed  at  the  junction  of  the  iliac  veins  and  inferior 
vena  cava  which,  becoming  engorged,  necessitated  a  collateral  cir- 
culation.     Curiously  enough,  the  patient  survived. 

Plugging  of  the  veins  to  a  great  degree  usually  results  in  moist 
gangrene,  as  has  already  been  stated. 

In  regard  to  the  vessels  most  commonly  affected  by  plugging, 
we  gain  very  interesting  information  once  more  from  Keen's  classic 
essay.  Out  of  90  cases  of  gangrene,  and  Keen  believes  all  these 
cases  were  due  to  plugging  of  vessels,  16  had  arterial  plugging,  of 
which  8  were  bilateral,  19  on  the  right  side,  and  19  on  the  left 
side.  In  the  veins  in  52  cases  there  was  bilateral  involvement  on 
both  sides  in  4  cases  ;  on  the  right  side  in  10  cases,  and  on  the  left 
side  in  38  cases.  Again,  in  those  cases  which  did  not  proceed  to 
gangrene,  Keen  found  plugging  in  the  arteries  in  15  cases,  of  which 
4  were  bilateral,  6  on  the  right  side,  and  5  on  the  left,  and  in  the 
veins,  out  of  47  cases,  3  were  bilateral,  13  on  the  right  side,  and 
31  on  the  left. 

These  statistics  support  the  earlier  ones  presented  to  us  by 
Liebermeister,  who  met  with  31  cases  of  thrombosis  in  the  veins 
of  the  lower  extremities  among  1743  typhoid  fever  patients,  the 

1  Comptes  Eendu  Soc.  Biol.,  1879,  6th  series,  vol.  iv.  parts  283. 

2  L' Union  Medicale,  1882,  p.   521. 

3  Progres  Med.,  1890,  viii.  998. 

4  Glasgow  Med.  Journal,  1892,  vol.  xxviii.  p.  54. 

5  Centralblatt  fur  Innere  Med.,  June  6,  1896. 

6  Glasgow  Medical  Journal,  July,  1893. 


COMPLICA  TIONS  I)  URISG  CON VA LESCENCE.  1 93 

majority  of  whom  were  men.  In  hi>  cases  also  thrombosis  usually 
did  not  appear  until  the  stage  of  convalescence,  and  rarely  as  early 
as  the  third  or  fourth  week.  Out  of  24  cases,  1  <5  of  which  were 
in  men  and  8  in  women,  the  vessels  became  plugged  eighteen 
times  in  the  crural  vein,  five  times  in  the  saphenous  vein,  and  once 
in  the  popliteal  vein.  Thrombosis  of  the  crural  vein  took  place 
in  both  sides  simultaneously  twice,  four  times  on  the  right  side, 
and  twelve  times  on  the  left.  The  saphenous  vein  was  affected  on 
the  right  side  once,  and  on  the  left  side  four  times,  and  the  throm- 
bosis in  the  popliteal  vein  was  also  left -sided  ;  in  other  words,  this 
accident  occurred  five  times  on  the  right  side  and  seventeen  times 
on  the  left.  The  frequent  occurrence  of  thrombosis  in  the  left 
crural  vein  rather  than  the  right,  is  believed  by  Liebermeister  and 
by  Keen  to  be  due  to  the  slight  pressure  exercised  upon  the  left 
common  iliac  vein  by  the  right  common  iliac  artery,  thereby  com- 
pressing the  vein. 

Sometimes  phlebitis  of  the  calf  of  the  leg  develops  in  place  of 
thrombosis  of  the  femoral  vein.  Thus  Arnaudet1  records  three 
cases,  one  in  a  woman  of  seventy-five  years,  another  in  a  woman 
of  fiftv  vears,  and  the  last  in  a  man  of  thirtv-ei^ht  vears. 

The  author  has  recently  had  under  his  care  a  case  of  this  kind 
occurring  in  a  girl  of  twenty  years,  on  the  left  side.  In  Arnau- 
det's  cases,  one  was  on  the  left  side,  the  other  two  on  the  right. 

The  rarity  with  which  plugging  of  a  vessel  in  the  upper  extremi- 
ties takes  place  is  remarkable.  Thus  in  128  cases  collected  by 
Keen,  only  4  involved  the  upper  extremities  alone ;  2  involved 
the  arm  and  leg,  and  124  were  limited  to  the  legs. 

Genito-urinary.  Orchitis  complicating  typhoid  fever  during 
the  progress  of  the  febrile  stage  is  very  rare,  but  a  case  was  recorded 
by  Marcus2  in  1812,  of  suppuration  of  the  scrotum  in  "  stupid  ner- 
vous fever."  Yulpian3  also  states  that  this  complication  may  fol- 
low grave  fevers.  It  is  emphatically  a  symptom  of  the  period  of 
convalescence.     Westcott  collected  for  Keen  thirty-two  cases,  but 

1  La  Xormandie  Med.,  November  1,  1891. 

2  Archiv  fiir  Med.  Erfahrungen,  Berlin,  1812,  i.  546. 

3  Dietionnaire  de  Med.,  1844,  2d  ed.,  xxix. 

13 


194     COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER. 

Eshner1  has  collected  forty-two  cases,  and  has  reported  one  in  his 
own  care.  The  contribution  of  Ollivier2  to  the  study  of  typhoid 
orchitis  is,  however,  very  exhaustive,  and  to  him  belongs  the  credit 
of  summarizing  most  of  the  literature  up  to  1883.  The  writer 
has  also  met  with  one  case ;  its  history  is  as  follows  : 

The  patient  was  a  physician,  twenty-two  years  old,  who  was 
admitted  to  my  wards  in  the  Jefferson  Hospital  on  January  29, 
1898,  with  a  history  of  having  been  ill  for  ten  days  with  frontal 
headache  lasting  four  days,  with  pains  in  the  lumbar  region,  and 
with  general  debility.  There  Avas  diarrhoea,  with  copious  watery 
evacuations  from  the  bowel,  and  rose  spots  were  present  upon  the 
cheek  and  the  abdomen.  Xose-bleed  occurred  after  the  patient 
came  under  observation.  Examination  of  the  blood  yielded  a 
positive  reaction  to  the  Gruber-Widal  test.  The  urine  was  albu- 
minous on  each  of  three  occasions,  but  tube-casts  were  not  found. 
The  disease  pursued  an  ordinary  and  uncomplicated  course,  defer- 
vescence taking  place  on  February  2 2d,  and  the  patient  was  dis- 
missed well  on  March  13th.  On  March  28th  he  was  seized, 
without  obvious  cause,  with  pain  and  swelling  in  the  left  testicle. 
The  pain  was  agonizing,  and  the  swelling  gradually  increased 
until  the  testicle  became  many  times  its  normal  size.  Dr.  Hor- 
witz  noted  the  pain  as  being  intense  in  a  degree  far  beyond  that 
ordinarily  encountered  in  cases  of  orchitis  of  gonorrhceal  origin. 
The  temperature  was  as  high  as  101°  between  March  31st  and  April 
2d,  and  it  reached  100.3°  on  April  19th.  Otherwise  it  was  prac- 
tically normal.  There  was  also  no  urethritis  or  urethral  discharge. 
A  slight  effusion  into  the  vaginal  tunic  took  place,  but  there  was 
no  noteworthy  involvement  of  the  epididymis.  With  the  appli- 
cation locally  of  an  ice-bag,  and  of  mercurial  and  belladonna 
ointments,  and  the  internal  administration  of  opiates,  pain  was 
relieved  and  swelling  subsided ;  but  it  became  evident  that  an 
abscess  was  forming  in  the  left  half  of  the  scrotum.  Accordingly, 
an  incision  was  made  by  Dr.  Horwitz  on  April  23d,  and  a  consid- 
erable quantity  of  pus,   together  with  a  portion  of  the  testicle, 

1  Philadelphia  Medical  Journal,  May  21,  1898. 

2  Eevue  de  Medecin,  1883,  pp.  829,  960. 


COMPLICATIONS  DURING  CONVALESCENCE.  195 

was  evacuated.  The  operation  was  a  success,  and  the  patient 
recovered. 

Ollivier1  believes  that  orchitis  is  more  common  than  is  generally 
thought.  He  reports  three  cases  of  his  own.  Liebermeister2  met 
with  it  three  times  in  250  cases,  and  SoreF  found  it  in  3  cases 
out  of  871  typhoid  fever  cases  seen  in  ten  years.  Eshner  also 
quotes  Betke,1  who  did  not  meet  with  it  in  the  records  of  1420 
cases,  and  Dopfer,5  among  927  fatal  cases,  did  not  meet  it  once. 
Holscher,6  in  the  celebrated  2000  cases  in  Munich,  records  a  case- 
ous orchitis  in  but  one  instance. 

As  already  stated,  Eshner's  paper  is  the  latest  and  most  exhaus- 
tive contribution  to  this  subject,  and  I  have  used  it  freely  in  these 
pages.  He  tells  us  that  in  "  forty-one  cases  it  occurred  during 
the  course  of  the  fever  in  12,  and  during  convalescence  in  29. 
It  set  in  in  1  case  during  the  second  week  of  the  fever,  in  5 
during  the  third  week,  in  1  during  the  fourth  week,  in  1  during 
the  seventh  week,  in  1  at  an  unstated  period  of  the  disease,  in  3 
toward  the  close  of  defervescence,  in  8  at  an  unstated  period  of 
convalescence,  in  8  during  the  first  week,  in  8  during  the  second 
week,  in  3  during  the  third  week,  iu  1  during  the  fourth  week, 
and  in  1  during  the  sixth  week.  There  was  no  apparent  relation 
between  the  severity  of  the  original  disease  and  the  occurrence  of 
the  complication,  which  attended  mild  equally  with  severe  attacks. 

"  The  onset  is,  as  a  rule,  abrupt,  and  may  take  place  while  the 
patient  is  still  abed  or  after  he  has  arisen  and  is  up  and  about. 
The  first  manifestation  is  often  pain  referred  to  the  scrotum, 
though  sometimes  there  is  a  chill,  with  elevation  of  temperature, 
acceleration  of  pulse,  and  headache,  so  that  a  recrudescence  or  a 
relapse  may  be  suspected.  The  pain  may  involve  the  testicle,  the 
epididymis,  and  even  the  spermatic  cord,  and  it  may  extend  into 

1  Revue  de  Medecin,  1883,  iii.  829,  861. 

2  Ziemssen's  Handbueh  du  speciellen  Path,  und  Tlierap,  1874,  ii.  B.  2,  189. 

3  Bulletin  et  Mem.  de  la  Soc.  Med.  des  Hop.,  1889,  lvi.  236. 

4  Deutsche  klinic,  1870,  42  and  48. 

5  Miinchener  med.  Wochenschr. ,  1888,  p.  620. 
8  Ibid.,  January  20,  1891,  p.  4:?. 


196     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 


the  loin.  Often  a  sense  of  weight  or  heaviness  in  the  testicle  is 
complained  of.  The  scrotum  may  become  red,  tense,  and  cedema- 
tous,  and  effusion  may  take  place  into  the  vaginal  tunic  of  the 
testicle.  Such  an  effusion  was  reported  in  nine  of  the  cases  in 
this  collection.  The  testicle  or  epididymis  or  both  become  swollen 
and  tender,  and  they  may  undergo  suppuration.  Such  an  outcome 
was  noted  in  nine  of  the  cases.  Micturition  is  sometimes  attended 
with  burning,  and  the  urine  may  contain  the  products  of  catarrhal 
inflammation,  viz.,  mucus,  epithelial  cells,  and  leucocytes.  As  a 
rule,  however,  there  is  no  urethritis  and  no  history  of  gonorrhoea. 
"  The  testicle  is  usually  attacked  first,  and  in  a  considerable 
number  of  cases  alone.  In  a  smaller  number  the  epididymis  suf- 
fers alone  or  first.  In  the  majority,  however,  both  organs  suffer. 
Thus,  orchitis  occurred  alone  in  13  cases,  epididymitis  alone  in  6, 
and  both  orchitis  and  epididymitis  in  20.  Both  sides  seem  to  be 
attacked  with  equal  frequency.  The  right  side  suffered  in  18 
cases,  the  left  also  in  18,  and  both  sides  in  1.  The  complication 
lasts,  in  its  acute  phase,  for  about  a  week  or  ten  days ;  sometimes 
its  duration  is  much  protracted  by  suppuration,  and  often  swelling 
and  induration  persist  for  a  long  time.  In  several  instances  the 
testicle  was  lost  wholly  or  in  part.  The  complication  occurs  most 
commonly  at  the  period  of  life  at  which  typhoid  fever  is  itself 
most  common.  Thus  of  26  cases  in  which  the  age  is  stated,  17 
occurred  between  fifteen  and  twenty -nine  years.  The  age  distribu- 
tion of  the  cases  in  which  information  upon  the  point  is  given,  is 
as  follows  :" 


Between    1  and    4  years 


10  " 

14 

15  " 

19 

20  " 

24 

25  " 

29 

30  " 

34 

35  " 

39 

40  " 

44 

45  " 

49 

Cases. 
1 
2 

4 
9 
4 
2 
2 
1 
1 


Of  Eshner's  cases,  37  are  from  French  sources,  2  from  English, 
2  from  American,  and  1  from  a  Swiss  source. 


COMPLICATIONS  DURING  CONVALESCENCE.  197 

The  cause  of  this  complication  is  not  easy  to  determine.  Some- 
times it  may  be  due  to  infection  by  the  bacillus  of  Eberth,  some- 
times from  pyogenic  organisms  not  peculiar  to  typhoid  fever. 
Probably  the  latter  are  the  more  common  cause.  That  typhoid 
bacilli  may  enter  the  testicle  is  proved  by  the  fact  that  they  have 
been  found  in  the  testicle  in  bodies  at  autopsy  by  Chantemesse  and 
Widal  without  there  being  any  signs  of  orchitis. 

That  the  bacillus  of  Eberth  may  be  the  cause  is  also  shown  by  a 
case  of  suppurative  epididymitis  coming  on  during  convalescence, 
which  Strasburger1  has  reported.  The  patient  was  a  man  of 
twenty-eight  years,  who  suffered  from  typhoid  fever,  the  diagnosis 
being  confirmed  by  the  Widal  test.  The  disease  ran  its  normal 
course,  and  during  defervescence  the  patient  suffered  from  an 
abscess  of  the  gum,  numerous  boils,  and,  finally,  from  an  abscess 
of  the  cheek.  A  microscopical  examination  of  the  pus  derived 
from  these  boils  did  not  reveal  any  micro-organisms.  Three 
weeks  after  the  defervescence  had  commenced  the  patient  suffered 
from  violent  pain  in  the  right  testicle,  which  became  swollen,  and 
an  examination  revealed  an  epididymitis,  and  forty-eight  hours 
later  fluctuation  appeared,  and  puncture  revealed  a  small  quantity 
of  pus.  Two  days  later  the  abscess  was  excised  and  the  patient 
made  a  complete  recovery.  Cultures  of  the  pus  revealed  the 
bacillus  of  Eberth. 

Bucquoy  has  asserted  that  such  attacks  are  the  result  of  mastur- 
bation— a  habit,  he  thinks,  frequently  practised  during  convales- 
cence. Hutchinson,  on  the  other  hand,  thinks  that  it  is  due  to 
thrombosis  of  the  spermatic  vein. 

The  orchitis  or  epididymitis  of  enteric  fever  differs  from  that 
due  to  gonorrhoea,  in  that  it  is  less  painful  and  usually  less  acutely 
inflamed.  It  is,  however,  rapid  in  its  course  to  recovery  or  sup- 
puration, as  a  rule,  and  is  usually  unilateral.  Usually  the  testicle 
is  first  affected,  and  later  the  epididymis. 

The  following  table  is  that  of  Eshneiy  and  gives  a  complete 
record  of  this  condition  as  it  exists  in  literature.      Twenty-seven 

1  Miinchener  medicinische  Wochenschrift,  January  3,  1899. 

2  Philadelphia  Medical  Journal,  May  21,  1898. 


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COMPLICATIONS  DURING  CONVALESCENCE.  201 

of  these  cases  had  been  previously  collected  by  Ollivier,  and  ten 
by  Westeott  for  Keen  : 

While  the  manuscript  of  this  part  of  this  essay  was  in  the 
printer's  hands  the  following  additional  cases  were  also  reported  : 

Bunts,1  of  Cleveland,  Ohio,  records  the  following  case  of  typhoid 
orchitis  :  W.  C,  aged  thirty-eight  years,  private  in  B  Troop,  First 
Ohio  Volunteer  Cavalry,  was  taken  sick  with  typhoid  and  ad- 
mitted to  the  Regimental  Hospital,  at  Lakeland,  Fla.,  August  1 2, 
1898.  He  had  never  previously  had  an  attack  of  typhoid  fever. 
The  fever  pursued  a  moderately  severe  course,  and  on  September 
15th  he  was  sent  home  to  Ohio  on  sick  furlough.  On  his  arrival 
at  home  he  was  practically  confined  to  his  bed  until  October  12th. 
On  October  13th  he  was  suddenly  attacked  by  a  severe  chill  and 
great  prostration.  He  was  immediately  sent  to  the  hospital,  and 
was  confined  to  his  bed  for  several  weeks  with  what  was  diag- 
nosticated by  his  attending  physician  as  a  relapse  of  the  typhoid. 
On  September  29th,  fourteen  days  after  his  discharge  from  the 
hospital  at  Lakeland  he  noticed  a  swelling  in  the  left  testicle.  The 
pain  was  moderately  severe,  increasing  as  the  swelling  increased, 
and  at  the  time  of  his  admission  to  the  hospital  in  Cleveland  he 
suffered  considerable  pain,  which,  however,  was  relieved  by  rest, 
elevation,  and  hot  applications.  The  relapse  was  severe  and  his 
condition  most  critical.  However,  convalescence  eventually  en- 
sued, but  the  orchitis  remained.  Xo  history  of  gonorrhoeal  or 
syphilitic  infection  could  be  elicited  and  the  orchitis  was  diag- 
nosticated to  be  a  sequel  of  typhoid  fever. 

Strapping  was  resorted  to  in  the  hopes  of  reducing  the  swelling, 
but  was  abandoned  at  the  end  of  a  week,  no  improvement  having 
taken  place.  After  this  symptoms  of  softening  and  breaking  down 
of  the  organ  became  manifest,  and  it  was  decided  to  remove  the 
testicle.  This  was  done  November  16,  1898,  the  only  item  of 
interest  connected  with  the  operation  being  that  the  pulse-rate 
during  the  entire  operation  ranged  from  160  to  180,  ether  being 
the  anaesthetic  given.     The  testicle  was  found  entirely  disorgan- 

1  Medical  News,  March  25,  1899. 


202     COMPLICATIONS  AND  SEQUEL  JE  OF  TYPHOID  FEVER. 

ized  and  a  considerable  amount  of  pus  was  also  present.  The 
specimen  was  sent  to  the  Pathological  Laboratory  of  the  Western 
Reserve  Medical  College  and  examined  by  Dr.  Howard,  who 
reported  that  it  contained  a  practically  pure  culture  of  the  typhoid 
bacillus. 

Beckett1  reports  the  following  case  of  epididymitis  complicating 
typhoid  fever  :  M.  G.,  aged  forty  years,  ran  a  rather  severe  course 
of  typhoid  fever ;  was  much  prostrated.  During  the  fourth  week 
of  the  disease  the  left  epididymis  became  greatly  swollen,  and  sup- 
puration resulted.  This  condition  did  not  cause  much  constitu- 
tional disturbance.  A  free  incision  and  gauze  packing  soon 
effected  a  cure. 

Alimentary  Tract  and  Associated  Organs  in  Late  Stages 
and  in  Convalescence.  The  affections  of  the  alimentary  canal 
after  typhoid  fever  are  not,  as  a  rule,  of  very  great  importance 
nor  of  great  frequency.  In  the  majority  of  instances  they  consist 
in  more  or  less  severe  signs  of  indigestion  due  to  three  factors, 
namely,  the  inordinate  appetite  of  a  patient  convalescing  from 
typhoid  fever,  which  often  leads  him  to  overload  his  stomach,  his 
inability  to  deal  with  ordinary  amounts  of  food  is  impaired  by 
his  generally  feeble  state,  and,  finally,  the  disordered  condition  of 
the  bowels,  as  represented  by  the  states  of  diarrhoea  or  constipa- 
tion, may  be  prime  factors  in  interfering  with  the  proper  digestion 
of  food. 

Obstinate  and  persistent  constipation  is  the  condition  of  the 
intestine  most  commonly  met  with,  and  it  varies  from  a  moderate 
form  readily  relieved  by  proper  diet  and  drugs  to  a  condition  in 
which  the  fecal  mass  must  be  dug  out  of  the  rectum  with  a  spoon. 
This  condition  is  due  to  two  chief  causes.  In  the  first  place  the 
tissues  are  so  dried  out  by  the  fever,  so  to  speak,  that  they  eagerly 
absorb  from  the  alimentary  canal  all  the  liquid  they  can  to  restore 
their  normal  moisture ;  and,  secondly,  the  prolonged  use  of  a  diet 
leaving  but  little  residue,  and  lack  of  exercise  is  a  causative  factor 
of  intestinal  atony,  even  if  the  ulceration  and  catarrhal  state  of 

1  Southern  California  Practitioner,  March,  1899. 


COMPLICATIONS  DURING  CONVALESCENCE.  203 

the  mucous  membrane  of  the  bowel  in  the  disease  are  not  consid- 
ered. 

Diarrhoea  may  also  be  a  factor  which  delays  the  patient's  rapid 
return  to  health,  and  it  arises  from  the  use  of  improper  food,  from 
catarrh  of  the  bowels,  or  from  the  presence  of  unhealed  ulcers  in 
the  colon,  or  even  in  the  small  intestine.  This  condition  of  faulty 
healing  of  the  ulcers  in  the  bowel  may  be  a  serious  factor  in  the 
patient's  case.  Rarely  serpiginous  ulceration  of  the  mucous  mem- 
brane of  the  bowel  is  present,  and  this  results  in  a  persistent  diar- 
rhoea of  a  dysenteric  type  with,  it  may  be,  loss  of  blood.  This 
condition  has  been  described  by  Jaccoud  in  France,  and  by  George 
B.  Wood  in  America,  and  by  many  other  clinicians  since  his 
time. 

In  other  cases  perforation  of  the  bowel  may  take  place  with 
death  therefrom  long  after  the  fever  has  departed.  Thus  Morin1 
has  recorded  a  case  in  which  perforation  occurred  as  late  as  the 
one  hundred  and  tenth  day.  Sometimes  these  ulcers,  by  affording 
foci  for  septic  infection,  cause  the  maintenance  of  a  low  grade  of 
fever  for  many  weeks.  They  are  not  true  typhoid  ulcers,  but  the 
result  of  profound  necrosis  of  the  intestinal  mucous  membrane 
resulting  from  advanced  intestinal  catarrh  and  debility. 

Under  the  name  of  diphtheria  of  the  intestinal  mucous  mem- 
brane, Liebermeister  has  described  a  condition  in  which  the  bowel 
is  affected  by  diphtheroid  sloughs.  Very  rarely,  if  ever,  are  these 
sloughs  truly  diphtheritic.  The  ulceration  underlying  them  may 
be  severe  enough,  however,  to  result  in  perforation  of  the  bowel, 
as  already  pointed  out. 

Gangrene  of  the  bowel  in  distinction  from  ulceration  and  local 
necrosis  is  still  more  rare.  It  is  probably  due  almost  always,  if 
not  always,  to  thrombosis  or  embolism  of  the  mesenteric  voh'Is. 
and  in  Hoffmann's  250  cases  at  autopsy  this  lesion  was  found  no 
less  than  nine  times.  In  six  of  these  it  affected  the  ileum,  in  two 
the  vermiform  appendix,  and  in  one  the  sigmoid  flexure  Tho-e 
cases  in  which  there  is  gangrene  of  the  appendix  are  probably  due 

1  Des  Perforations  Intestinal  dans  le  Cours  de  la  Fifevre  Typhoide,  Paris,  1S69. 


204     COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER. 

to  appendicitis,  produced  by  direct  infection  by  the  bacillus  of 
Eberth  or  by  the  bacillus  coli  communis.      (See  earlier  chapter.) 

Peritonitis  arising  from  infection  from  the  ulcers  in  the  bowel 
wall  or  from  perforation  may  also  arise  in  this  period  of  the  dis- 
ease. Tschudnowsky1  records  a  case  of  this  character  in  which, 
after  typhoid  fever,  perforation  occurred  with  the  escape  of  gas 
into  the  peritoneal  cavity.  Auscultation  in  this  case  revealed  an 
exquisite  amphoric  murmur  on  inspiration  due,  it  was  thought,  to 
the  escape  of  gas  through  the  opening  in  the  gut. 

Cicatricial  contraction  of  the  bowel  due  to  the  healing  of  the 
ulcers  is  an  exceedingly  rare  condition,  which  is  a  curious  fact, 
when  we  consider  how  severe  the  ulcerative  process  may  be. 
Young2  has  recorded  a  case,  however,  in  which  the  lower  twenty- 
five  inches  of  the  ileum  were  so  greatly  contracted  that  the  first 
joint  of  the  thumb  could  not  be  inserted  into  the  bowel.  In  this 
case,  too,  about  two  inches  above  the  ileo-csecal  valve  there  was 
constriction,  almost  to  the  point  of  occlusion,  and  a  similar  nar- 
rowing existed  at  the  upper  end  of  the  contracted  portion  of  the 
bowel.  Above  this  upper  constriction  the  small  bowel  was  so 
dilated  that  it  resembled  a  stomach.  The  patient  died  as  the  result 
of  a  fall  from  a  horse  long  after  the  typhoid  attack. 

Concerning  the  more  infrequent  complications  affecting  the 
alimentary  tract  at  this  period,  we  find  a  number  of  interesting 
facts.  Noma  has  been  recorded  in  a  few  cases,  notably  by  Frey- 
muth  and  Petruschky,3  who  report  a  case  of  noma  of  the  cheek  in 
a  case  of  typhoid  fever  in  which  virulent  diphtheria  bacilli  were 
isolated  from  the  gangrenous  tissue,  and  in  which  healing  followed 
the  use  of  antitoxic  serum.  Keen  collected  nine  cases  in  his  Toner 
Lecture  in  1876,  although  some  of  these  were  rather  those  of  can- 
crum  oris  than  true  noma,  and  Hall  has  reported  to  Keen  a  case 
which,  as  Keen  says,  if  not  one  of  noma  was  at  least  akin  to  it.  The 
patient  died  of  hemorrhage  from  the  area  involved  on  the  thirty- 
eighth  day  of  the  general   malady.     So,  too,  Littlejohn4  has  re- 

1  Berliner  klin.  Wochenschrift,  1869,  Nos.  20,  21. 

2  Medical  Press  and  Circular,  1886,  xlvi.  p.  471. 

3  Deutsche  med.  Wochenschrift,  1898,  No.  15,  p.  232,  and  No.  38,  p.  500. 

4  British  Medical  Journal,  April  30,  1893. 


COMPLICATIONS  DURING  CONVALESCENCE.  205 

corded  two  fatal  cases  of  noma  following-  typhoid  fever.  In  one 
of  these  both  cheeks  sloughed ;  in  the  other  there  was  not  only 
sloughing  of  one  check,  but  gangrene  of  the  skin  of  the  hip. 

Aphthous  inflammations  of  the  mouth  may  be  present  in  rare 
cases,  and  is  usually  seen  only  in  patients  who  are  in  crowded 
wards  or  barracks,  in  which  careful  attention  cannot  be  paid  to 
individual  eases. 

Glossitis  may  occur  in  typhoid  fever,  but  is  very  rare.  Osier 
has  recorded  a  case  which  developed  glossitis  ten  days  after  his 
temperature  was  normal,  but  recovery  ensued  in  a  few  days. 

Alveolar  abscess  may  also  occur,  and  Liebermeister  records  a 
case  in  which  there  was  emphysema  of  the  cheek  of  the  afflicted 
side. 

Franklin1  has  reported  a  case  in  which  gangrene  began  in  the 
upper  gum  and  caused  in  five  days  necrosis  of  the  superior  maxilla. 

A  case  of  gangrene  of  the  mouth  and  partial  necrosis  of  the 
superior  maxillary  bone  has  been  reported  by  Winkouroff,2  as 
occurring  in  a  little  girl  six  years  old.  The  left  cheek  was 
observed  to  be  swollen  on  the  first  day  of  the  illness ;  on  the 
third  day  a  black  spot  made  its  appearance  in  the  back  of  the 
mouth  ;  on  the  seventh  day  the  eschar  suppurated  and  perforation 
of  the  cheek  occurred.  The  most  noteworthy  fact  in  this  case  is 
that  of  recovery. 

Induration  followed  by  softening  and  perforation  of  the  cheek, 
and  finally  by  death,  has  been  reported  by  Donald3  as  having 
occurred  in  two  sisters  during  the  course  of  typhoid  fever.  In 
both  cases  the  right  cheek  was  affected.  I  have  under  my  care 
at  present  a  woman  convalescing  from  a  most  grave  attack  of 
typhoid  fever,  with  an  abscess  forming  in  the  wall  of  the  right 
cheek  which  is  not  connected  with  the  parotid  gland  or  Steno's 
duet. 

Keim'  has  reported  a  fatal  case  of  typhoid  fever  in  a  boy  of 

1  Quoted  by  Hutinel. 

2  Bulletin  de  la  Societe"  Anatomique,  December,  1887. 

3  London  Lancet,  February  20,  1893. 

1  Lehigh  Valley  Medical  Magazine.  October,  1891. 


206     COMPLICATIONS  AND  SEQUEL JE  OF  TYPHOID  FEVER. 

nine  years,  in  which  gangrene  of  the  left  cheek  occurred  during 
convalescence.     Two  other  cases  are  reported  in  the  same  journal. 

Another  case  has  been  reported  by  Clark,1  in  which  a  man  of 
twenty-eight  years  suffered  on  the  thirtieth  day  of  typhoid  fever, 
with  bulging  of  the  right  cheek,  followed  by  closure  of  the  right 
eye  and  great  swelliug  of  the  lids,  and  on  the  thirty-third  day  the 
left  eyelids  became  involved,  and  on  the  thirty-fifth  day  large 
non-glandular  swellings  appeared  at  the  angles  of  the  lower  jaw. 
The  right  upper  eyelid  sloughed  away,  and  the  patient  died  of 
exhaustion  on  the  thirty-seventh  day  of  the  illness.  It  is  thought 
that  the  local  condition  was  the  result  of  a  general  infection. 

Sloughing  of  the  face  in  a  child  of  twelve  years,  ending  fatally, 
is  reported  by  Ewens.2  In  this  case  the  sloughing  really  followed 
an  attack  of  measles  and  mumps  which  occurred  during  convales- 
cence in  typhoid  fever. 

Gangrene  of  the  tongue  has  been  reported  once  by  Gaston 
David,3  while  Freudenberger4  has  seen  it  involve  the  uvula. 
Spillmann5  met  with  gangrene  of  the  lips  with  final  septicaemia 
due  to  a  secondary  staphylococcus  infection,  which  destroyed  life. 

Liebermeister  records  one  case  of  melanotic  softening  of  the 
oesophagus  after  typhoid  fever. 

(Esophageal  ulceration6  may  lead  in  some  cases  to  stricture.  A 
case  has  been  reported  by  Packard,  and  one  by  Mitchell  which 
occurred  in  Osier's  wards. 

A  case  of  ulcer  of  the  oesophagus  has  been  recently  reported  by 
Eiesman  to  the  Pathological  Society  of  Philadelphia,  March  9, 
1899.     (Fig.  19.) 

In  regard  to  lesions  coming  on  at  the  other  end  of  the  ali- 
mentary canal  after  enteric  fever  we  find  a  case  of  gangrene  of 


1  London  Lancet,  April  9,  1893. 

2  London  Lancet,  August  4,  1889. 

3  Quelques  Considerations  sur  la  Gangrene  Typhoide.     These  de  Paris,  1887. 
*  Aertzliche  Intelligenzblatt,  1880,  xxvii.  7. 

5  Merc.  Medicale,  1895,  No.  13,  145. 

6  A  valuable  paper,  by  Russell,  on  oesophageal  ulceration  in  general  is  to  be 
found  in  the  Scottish  Medical  and  Surgical  Journal  for  April,  1899. 


COMPLICATIONS  DURING  CONVALESCENCE.  207 

the  anus  reported  to  Keen  by  Betz,  of  Oakville,  Pa.,  the  condition 
arising  in  all  probability  from  general  thrombosis  of  the  hemor- 
rhoidal arteries.  This  patient  was  a  boy  of  ten  years,  who  at  the 
end  of  the  fifth  week  complained  of  irritation  about  the  anus,  the 
parts  being  found  slightly  discolored.      Within   twelve  hours  the 

Fig.  19. 


Riesman's  case  of  ulcer  of  the  oesophagus  in  typhoid  fever.      (Case  reported  in 
the  Philadelphia  Pathological  Society's  Transactions,  March,  1899. ) 

tissues  of  the  ischio-rectal  fossa  sloughed  out  and  the  rectum  was 
found  to  be  gangrenous.  It  speedily  separated,  leaving  a  large 
opening.  Curiously  enough,  absolute  recovery  took  place,  the 
♦evacuations  being  finally  perfectly  controlled. 


208     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

Cases  of  gangrene  of  the  perineum  and  anus  may  occur  from 
extension  of  the  process  from  the  vulva  in  "women.  Keen  gives 
interesting  facts  concerning  these  cases  which  are  not  medical  con- 
ditions and,  therefore,  need  not  be  discussed  at  this  time. 

Passing  on  to  the  lesions  found  in  the  organs  associated  with 
the  alimentary  canal,  we  find  that  inflammation  of  the  parotid 
gland  is  an  unusual  complication  of  typhoid  fever,  and  is  due  to 
extension  of  infection  from  a  foul  mouth  through  Steno's  duct. 
In  rare  instances,  however,  the  parotitis  is  due  to  true  typhoid 
infection.  Thus  Janowski1  records  a  case  of  a  man  of  twenty 
years  who  died  in  the  "  second  or  third  month "  of  the  fever. 
The  bacillus  of  Eberth  was  found  to  be  the  infecting  organism  in 
the  gland.  In  another  case,2  both  the  bacillus  of  Eberth  and  the 
staphvlococcus  were  found  to  be  present.  Sometimes  the  inflam- 
matory process  goes  no  further  than  swelling  and  hyperemia  ;  in 
others  suppuration  develops,  and  when  it  does  the  destruction  of 
tissue  is  usually  grave,  not  only  in  the  gland  but  in  nearby 
tissues  as  well.  Curiously  enough,  the  other  salivary  glands  are 
almost  never  affected.  Xot  only  may  the  local  necrosis  be  dan- 
gerous in  itself,  but  if  the  pus  is  not  given  free  vent  it  is  apt  to 
burrow  down  between  the  tissues  of  the  neck  and  cause  septi- 
caemia or  pyaemia  by  infecting  the  great  vessels  and  lymphatics. 
Facial  palsv  may  result  either  from  destruction  of  the  facial 
nerve,  by  its  section  in  incising  the  abscess,  or  by  reason  of  the 
pressure  exercised  upon  the  nerve  as  it  passes  through  the  stylo- 
mastoid foramen,  the  neighboring  bony  tissues  being  involved. 
In  regard  to  the  frequency  of  this  condition,  we  find  that  Hoff- 
mann met  with  suppurative  parotitis  in  16  cases  out  of  1600 
patients,  and  that  7  of  these  died.  Ordinary  parotitis  occurred 
in  3  cases.  In  15  cases  the  attack  was  limited  to  one  side,  9 
times  in  the  right  and  6  times  in  the  left.  Keen  collected  26 
cases  in  his  Toner  Lecture  of  1876,  and  50  more  in  his  recent 
essay.     Thirty  per  cent,  of  these  died,  and  20  of  the  28  cases  in 

1  Centralblatt  Bacteriol.  und  Parasit.,  1895,  xvii.  685. 

2  Lehman.     Centralblatt  fur  klin.  Med.,  August,  1891,  649. 


COMPLICATIONS  DURING  CONVALESCENCE.  209 

which  the  sex  was  named  were  males.  Twenty-nine  of  his  cases 
suppurated  and  only  5  did  not.  In  12  the  trouble  was  bilateral, 
and  7  of  these  suppurated  on  both  sides. 

Parotitis  is  a  lesion  of  the  third  or  fourth  week,  and  is  of  evil 
omen,  since  it  shows  degenerative  changes  in  other  important 
glands. 

Osier  has  recorded  a  case  in  which  a  right  parotid  abscess  com- 
plicated typhoid  fever  in  a  man  who  was  ill  in  September,  1890. 
In  January,  1896,  when  Osier  saw  him,  he  had  profuse  sweating 
over  the  right  side  of  the  face  and  temple  on  eating,  this  condition 
having  lasted  more  than  five  years.  There  was  no  facial  anaes- 
thesia or  paralysis. 

The  liver  may  become  affected  by  various  conditions  in  conva- 
lescence. Of  these  we  find,  as  most  important,  abscess,  cholangitis, 
and  cholecystitis. 

Here,  again,  the  exhaustive  monograph  of  Keen  may  be  referred 
to  as  presenting  many  of  the  facts  we  have  concerning  this  organ. 
Abscess  of  the  liver  is  seldom  met  with,  for  Keen  found  only 
twenty-one  cases  in  literature.  Solitary  abscess  is  due  to  the  ba- 
cillus coli  communis,  to  the  staphylococcus,  or  to  the  bacillus  of 
Eberth,  and  is  very  rare.  Osier  has  not  met  with  it  once,  and  in 
the  Munich  2000  autopsies1  it  was  only  met  with  in  twelve  cases, 
while  Dopfer,  in  927  cases,  found  abscess  in  only  ten  of  them. 
Out  of  the  twenty-one  cases  of  solitary  abscess  no  less  than 
nineteen  cases  died. 

When  there  are  septic  foci  elsewhere  the  abscess  is  usually 
secondary  and  multiple.  Louis  has  recorded  a  case  of  hepatic 
abscess  associated  with  parotid  suppuration,  and  Chvostek  one  con- 
secutive to  perichondritis  of  the  larynx.  Delaire2  has  reported  an 
instance  in  which  an  hepatic  abscess  ruptured  into  a  bronchus ; 
the  abscess  was  incised  and  recovery  occurred. 

Lannois  reports  the  following  ease,  which  occurred  in  the  Hopi- 
taux  Militaire  de  la  ( 'haritc  in  1881  :  A  man  of  twenty-two  year-, 

1  Holscher.     Miinchener  med.  Woclienschrift,  1S91,  Nos.  3  and  4. 

2  Gazette  des  H6pitaux,  1869. 

1  I 


210     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

after  several  days  of  malaise,  presented  all  the  signs  of  adynamic 
enteric  fever.  In  the  third  week  he  became  intensely  jaundiced, 
"  fairly  black;  "  the  liver  was  enlarged  ;  there  was  active  delirium 
and  intense  pulmonary  congestion.  Eleven  days  after  the  onset 
of  the  jaundice  a  small  superficial  abscess  appeared  on  the  back  of 
the  left  hand  and  on  the  right  side  of  the  face.  The  autopsy 
revealed  the  ordinary  lesions  of  typhoid  fever,  congestion  of  the 
lungs,  and  an  enormous  hepatic  abscess  of  3000  grammes  (3 
quarts).  The  pus  was  yellow  and  greasy,  and  the  gall-bladder 
was  distended  with  clear  liquid  and  muco-pus.  The  other  case 
recorded  by  Lannois1  is  somewhat  different  from  this,  in  that  the 
symptoms  of  abscess  developed  after  the  fever  had  ceased.  On 
the  third  day  of  apyrexia  the  patient,  who  was  a  young  man  of 
twenty-eight  years,  was  seized  by  a  violent  chill,  followed  by  high 
fever  and  at  the  same  time  by  signs  of  "  pleuro-pulmonary  "  dis- 
ease at  both  bases,  but  chiefly  at  the  right  base.  Ten  days  later 
the  belly  was  tympanitic,  and  there  was  tenderness  in  the  hypo- 
chondrium  of  the  right  side.  Rapid  emaciation  ensued ;  the  pulse 
became  feeble,  and  the  patient  oppressed.  Sharp  pain  was  suffered 
in  the  epigastrium.  There  was  no  oedema  or  albuminuria.  The 
autopsy  revealed  old  lesions  of  enteric  fever,  and  in  the  vena  porta 
a  large  thrombus  which  extended  into  all  the  neighboring  branches. 
Ten  large  abscesses  were  found  in  the  lower  part  of  the  right  lobe 
of  the  liver.  They  varied  in  size  from  a  mandarin  orange  to 
that  of  an  egg.  The  pus  was  creamy  yellow.  Pleural  effusion 
was  present. 

Multiple  abscesses  of  the  liver  have  been  recorded  by  Romberg2 
after  a  severe  attack  of  typhoid  fever  complicated  by  hemorrhage 
and  followed  by  jaundice  ;  death  occurred.  Miliary  abscesses  were 
scattered  through  the  liver  in  large  numbers,  and  there  was  sup- 
puration of  the  mesenteric  glands  with  thrombosis  of  the  portal 
vein  and  its  branches. 


1  Kevue  de  Medecin,  1895,  p.  913.     Pylephlebite  et  Absces  de  Foie  Consecutif 
a  la  Fievre  Typhoide. 

2  Berliner  klin.  Wochensclirift,  March  3,  1891. 


COMPLICA  TIONS  D  URING  CONVA LESCENCE.  2 1 1 

Another  case  of  multiple  hepatic  abscess  complicating  convales- 
cence in  typhoid  fever,  has  very  recently  been  reported  by  Herman,1 
of  Memphis.  The  patient  was  a  man  of  twenty -six  years,  a  fireman 
by  occupation,  who  on  the  thirty-third  day  of  his  illness  was  seized 
with  a  chill  and  severe  lancinating  pain  in  his  right  side,  followed 
by  a  rise  in  temperature  and  marked  tenderness  in  the  liver,  but 
no  physical  signs  of  pulmonary  trouble.  Three  days  later  the 
patient  suffered  from  rigors  and  sweats.  An  aspirator  revealed 
pus,  and  upon  the  ninth  rib  being  resected,  six  ounces  of  choco- 
late-colored pus  escaped.  Later,  another  rise  in  temperature  with 
sweats  indicated  the  presence  of  further  pus-formation,  and  explo- 
ration revealed  additional  abscesses  which  discharged  pus  when 
their  walls  were  broken  down  by  the  finger  of  the  operator.  This 
happened  a  third  time,  and  in  each  instance  when  the  pus  was 
evacuated  temporary  improvement  took  place,  but  the  patient 
finally  died  from  exhaustion. 

Suppurative  pylephlebitis  is  another  rare  state  and  may  cause 
hepatic  abscess.  It  arises  usually  as  the  result  of  thrombosis  of 
the  vena  porta.  Schultz  found,  in  studying  the  statistics  of  3686 
cases  of  typhoid  fever  in  Hamburg,  that  302  deaths  occurred,  but 
no  instance  of  this  condition  was  met  with.  Buckling2  found  this 
lesion  in  two  cases.  Romberg,3  who  studied  677  cases  with  88 
deaths,  found  one  instance,  although  he  refers  to  four  more. 
Staphylococci  were  found  in  the  thrombi  and  in  the  pus.  Osier4 
saw  one  case  in  which  multiple  abscess  of  the  mesentery  was  pres- 
ent, and  the  portal  vein  outside  of  the  liver  was  an  elongated 
abscess.  So,  too,  Lannois5  records  a  case  of  thrombosis  of  the 
portal,  splenic,  and  inferior  mesenteric  veins,  with  multiple  hepatic 
abscesses.  In  this  case  the  specific  bacillus  was  found  in  the  pus. 
Klebs6  has  recorded  a  case  of  suppurative  cholangitis  in  which  the 
bile  passages  were  dilated  into  large  abscess  cavities. 

Cholecystitis,  unlike  the  hepatic  complications  of  typhoid  fever 

1  Memphis  Lancet,  1899.  z  Falle  von  Leber  Abscesse,  Berlin,  1868. 

8  Berlin,  klin.  Wochenscbrift,  1890,  192. 

4  Trans.  Assoc.  American  Physicians,  1897,  382. 

5  Eevue  ele  Medicin,  1895,  909.  6  Handbuch  der  Pathol.  Anatomic 


212     COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER. 

just  reviewed  is  as  common  as  they  are  rare.  Thus  Louis1  states 
that  changes  in  the  gall-bladder  are  much  more  frequent  in  the 
course  of  typhoid  fever  than  in  any  other  disease. 

"Westcott  collected  for  Keen  74  cases  of  true  typhoid  infection 
of  the  gall-bladder,  of  which  30  were  operated  on.  Notwith- 
standing this  comparatively  small  number  in  which  the  bacillus 
was  proved  to  be  the  cause  of  the  affection,  literature  teems  with 
cases  iu  which  typhoid  cholecystitis  was  present.  Aside  from 
Louis's  description  of  it,  we  find  Andral  and  Grisolle  writing  on 
it  as  long  ago  as  1835,  and  later  Rokitansky,2  Frerichs,3  and 
Budd4  recorded  such  cases.  In  America  as  long  ago  as  1846 
Ayres5  reported  the  case  of  a  young  physician  so  affected,  who 
died  of  peritonitis,  and  Murchison6  tells  us  that  "  fatal  peritonitis 
may  result  from  ulceration  of  the  gall-bladder  proceeding  to  per- 
foration." 

Among  those  who  have  written  on  this  very  important  theme 
still  more  recently  we  may  name  Chiari,7  Dupr§,8  Courvoisier,9 
and  Hagenmuller,10  the  latter  collecting  eighteen  cases. 

It  was  not  until  1890  that  Gilbert  and  Girode11  proved  that 
suppurative  cholecystitis  arose  from  typhoid  infection. 

It  has  also  been  proved  that  the  bacillus  of  Eberth  may  remain 
for  many  months  in  the  gall-bladder  before  it  produces  grave 
disorders.  Thus  Dupre12  records  a  case  in  which,  at  a  chole- 
cystotomy,  the  bacilli  were  found  in  the  gall-bladder  six  months 

1  Typhoid  Fever,  Trans.  Bigelow,  1836,  vol.  i.  269. 

2  Manual  of  Path.  Anat.  Sydenham  translation,  vol.  ii.  p.  160. 

3  Disease  of  Liver,  vol.  ii.  p.  454.     Sydenham  translation. 

4  Diseases  of  Liver,  3d  American  ed. ,  Philadelphia,  1857. 

5  New  York  Journal  of  Medicine,  1846,  vol.  vii.  p.  315. 

6  Continued  Fevers  of  Great  Britain,  pp.  566  and  634. 

7  Ueber  Cholecystitis  Typhosa.     Prager  med.  Wochenschrift,  1893,  No.  22. 

8  Les  Infections  Biliares.     These  de  Paris,  1891. 

9  Casuistisch  Statistische  Beitriige  ziir  Pathologie  und  Chirurgie  der  Galbur- 
wega,  Leipzig,  1890,  pp.  76  and  94. 

10  Cholecystitis  Typhosa.     These  de  Paris,  1876. 

11  Mem.  de  la  Societe  de  Biol.,  1890;  La  Semaine  Med.,  1890,  No.  58,  and 
Mem.  de  la  Societe  de  Biol.,  1893,  p.  986. 

12  Les  Infections  Biliares.     These  de  Paris,  1891. 


COMPLICA  TIONS  D  URING  CONVALESCENCE.  213 

after  the  fever  ceased,  and  Chantemesse1  records  an  instance  eight 
months  after  the  fever,  while  von  Dungen2  recites  one  remarkable 
instance  of  cholecystitis  fourteen  and  a  half  years  after  the  fever. 
In  the  pus  of  this  case  the  Eberth  bacillus  was  fou/nd. 

The  American  writers  on  this  topic  have  been  chiefly  Mason,3  of 
Boston,  and  Osier.4  Mason  tells  us  that  the  records  of  the  Boston 
City  Hospital  show  only  three  cases  of  this  character  other  than 
his  own.  Two  of  these  died.  His  own  case  recovered  after  the 
gall-bladder  had  been  tapped. 

In  many  of  these  cases  gallstones  have  been  found  present,  and 
these  probably  aid  in  opening  the  way  for  infection,  but  Bernheim5 
and  Chantemesse0  advance  the  view  that  the  infection  aids  in 
forming  the  stones.  So  firm  are  the  French  in  the  belief  that 
this  view  holds  true  that  they  called  this  form  of  the  disease 
"hepatic  typhoid,"7  and  Dufourt8  has  recorded  nineteen  cases  of 
biliary  lithiasis  which  had  their  first  attacks  after  enteric  fever  and 
all  of  them  within  ten  months  of  the  fever.  Gilbert  and  Four- 
nier9  divide  cholelithiasis  into  two  groups  :  those  which  are  the 
more  numerous,  being  due  to  the  colon  bacillus,  and  the  less  fre- 
quent form,  due  to  the  bacillus  of  typhoid  fever. 

A  case  has  been  recorded  by  Anderson10  in  a  man  of  sixty-seven 
years,  who,  two  months  after  typhoid  fever,  was  seized  with  intense 
pain  in  the  right  hypochondrium,  followed  by  death  in  ten  days. 
The  autopsy  revealed  peritonitis  and  perforation  of  the  gall- 
bladder due  to  the  bacillus  of  Eberth  or  the  bacillus  coli  com- 
munis. Alexieef u  also  reports  a  case  in  which  a  child  of  five 
years  suffered  from  a  pear-shaped  tumor  in  the  hepatic  area,  and 
great  pain.    Operation  revealed  suppurative  cholecystitis,  with  the 

1  Traits  de  Med,  i.  764. 

2  Miinchener  med.  Wochenschrift,  1897,  No.  26,  699. 

3  Transactions  Assoc.  American  Phys.,  1897,  xii.  p.  23. 

4  Ibid.,  p.  378.  5  Diet.  Encyclo.  de  Dechambre,  1889.     Entire  art. 

6  Quoted  by  Dupre,  loc.  cit. 

7  Landouzy.     Gaz.  des  Hopitaux,  1883,  8-41,  or  Matliieu,  Rev.  de  Mc'd.,  1886. 

8  Revue  de  Med.,  Paris,  1893,  p.  247. 

9  Compte-rendus  Soc.  Biol.,  March  5,  1897,  p.  936. 

111  (  an ada  Lancet,  1896.  "  Quoted  by  Osier,  ibid. 


214     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

typhoid  bacillus  in  the  pus  ;  recovery  occurred.  Hawkins1  reports 
a  case  of  this  character  in  which  after  death  there  were  found 
typhoid  lesions,  and  Osier2  records  four  cases,  three  of  which 
recovered  and  1  died.  He  also  records  two  cases  of  hepatic  colic. 
one  of  which  followed  enteric  fever,  and  one  which  had  typhoid 
bacilli  in  the  gall-bladder  without  having  had  typhoid  fever. 
Cushing3  tells  us  that  a  prior  history  of  typhoid  fever  is  often  met 
with  in  gallstone  cases  in  Halsted's  clinic  at  Baltimore ;  and  that 
it  occurs  in  the  proportion  of  10  in  31  cases.  Hektoen*  also  tells 
us  that  he  has  recently  seen  a  case  in  which  the  pus  from  a  sup- 
purative lithiasis  of  the  gall-bladder  gave  the  WIdal  reaction.  This 
patient  had  typhoid  fever  six  years  before.  Cushing  has  also 
reported  in  the  Johns  Hopkins  Hospital  Bulletin  for  May,  1898, 
a  case  in  which  cholecystotomy  was  performed  for  a  cholecystitis, 
in  which  the  typhoid  bacillus  was  found,  although  there  Avas  no 
history  of  typhoid  fever.  The  blood  in  Cushing' s  case  also  gave 
the  typhoid  reaction.  Cushing  suggests  that  the  typhoid  bacilli 
enter  the  gall-bladder,  as  they  have  been  shown  to  do  by  Futterer,5 
and  remain  alive  a  long  time,  during  which  an  agglutinative  re- 
action takes  place,  forming  a  clump  about  which  the  material  for 
the  formation  of  a  stone  clusters. 

Finally,  it  is  interesting  to  note  that  in  the  mind  of  no  less  a 
pathologist  than  Chiari,  it  is  held  that  relapses  in  typhoid  fever 
may  ensue  from  the  gall-bladder  infection. 

The  diagnosis  of  gall-bladder  infection  rests  on  the  following 
points  :  Tenderness  on  pressure  a  little  above  and  to  the  right  of 
the  umbilicus.  There  is  pain  in  the  gall-bladder  and  under  the 
scapula,  and  often  a  pear-shaped  mass  can  be  detected  in  the  ante- 
rior hypochondrium.  This  may  fluctuate.  If  perforation  occurs 
peritonitis  speedily  develops.  As  Mason  well  says,  in  diagnosis 
we  must  exclude  impacted  feces,  hydronephrosis,  cyst,  displaced 
kidney,  and  appendicitis,  and  when  rupture  of  the  gall-bladder 

1  Lancet,  January  30,  1897.  2  Ibid. 

3  Johns  Hopkins  Hospital  Bulletin,  May,  1898,  No.  86. 

4  Progressive  Medicine,  March,  1899. 

5  Miinchener  med  Wochenschrift,  1888,  No.  19. 


COMPLICA  TIONS  D  URING  CON VA  LESCENCE.  215 

has  occurred,  intestinal  perforation.  Leucocytosis  would  be  indi- 
cative of  acute  cholecystitis  and  appendicitis. 

The  prognosis  of  cholecystitis  is  grave.  Only  one-quarter  of 
the  cases  collected  by  Mason  got  well.  The  mortality  of  perfora- 
tion of  the  gall-bladder  is  very  high.  Twenty-six  cases  not  oper- 
ated on  died ;  of  four  operated  on,  three  recovered  and  one  died. 
For  further  statistics  the  reader  is  referred  to  Keen's  essay. 

The  following  cases  illustrating  cholecystitis  collected  by  Mason 
are  of  interest  : 

"Case  1.  Leudet.1  Female,  aged  thirty-six  years.  Fourth 
week,  pyriform  tumor  in  right  hypochondrium,  disappearing  in 
ten  days  ;  reappearing  at  intervals  during  seven  weeks.  No  jaun- 
dice.    Recovery. 

"Casel.  Griesinger.2  Female,  aged  twenty  years.  Sixth  week, 
peritonitis,  slight  icterus.  Painful  tumor  to  right  of  umbilicus. 
Swelling  of  liver  ;  collapse  ;  convalescence.  In  eighth  week  sud- 
den return  of  tumor,  with  chills,  icterus,  vomiting  ;  later,  two 
more  relapses.     Recovery  fifth  month. 

"  Case  3.  Laveran.3  Man,  aged  twenty-three  years.  Painful 
symptoms  and  tumor  in  region  of  gall-bladder  in  sixth  week. 
Recovery. 

"  Case  4.  Martin-Solon.4  Patient  died  of  peritonitis,  and 
twenty-five  ulcers  of  gall-bladder  were  found.  Previous  illness 
not  clearly  typhoid  fever.     Entente  (?). 

"  Case  5.  Husson.5  Child,  aged  eight  years.  Died  at  end  of 
third  week.  Perforated  gall-bladder.  Cystic  duct  obliterated  and 
converted  into  fibrous  cord. 

"  Case  6.  Dumoulin.6  Man,  aged  nineteen  years.  Third  week, 
constant  nausea  and  vomiting.  Enormous  tumor  in  right  hypo- 
chondrium, extending  to  left  of  umbilicus  and  into  right  iliac  fossa. 
Resistance  like  tense  hydrocele.  Liver  raised.  Upper  limit  line 
of  right  nipple.     Diagnosis :    distended  gall-bladder.     Repeated 

1  Hagenmiiller,  ibid.  2  Ibid.  3  Ibid. 

4  Bull.  Fac.  de  Med.  de  Paris,  1820-'21,  vii.  pp.  370-375. 

5  Bull,  de  la  Soc.  Anat.,  1893,  p.  104. 

6  Gaz.  Med.  de  Paris,  1884,  3d  series,  tome  iii.  p.  551. 


216     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

chills,  suggestive  of  hepatic  abscess.  Coma  ;  death,  sixteenth  day. 
Autopsy  :  typical  intestinal  lesions  of  typhoid ;  tumor,  size  of  head, 
containing  two  litres  of  greenish  bile ;  no  gallstones  ;  adhesions 
with  liver,  transverse  colon,  etc. 

"  Case  7.  Archambault.1  Infant,  thirtieth  day,  signs  of  intes- 
tinal perforation.  Death  twelve  days  later.  Perforation  of  gall- 
bladder ;  localized  peritonitis. 

"Case  8.  Barthez  and  Rilliet.2  Girl,  aa*ed  twelve  vears.  Six- 
teenth  day,  tumor  in  right  hypochondriurn,  which  gradually  disap- 
peared. Death,  fifty-second  day.  Autopsy :  perforated  gall- 
bladder ;  circumscribed  pus  cavity  between  liver,  stomach,  gall- 
bladder, and  colon. 

"  Case  9.  Ranvier.3  Man,  aged  twenty-eight  years.  Died 
during  convalescence  in  the  fifth  week.  Autopsy  :  limited  perito- 
nitis ;  perforated  gall-bladder ;  right  side  of  abdomen  filled  with 
yellowish,  opaque  liquid.  Walls  of  gall-bladder  two  or  three 
millimetres  thick  and  infiltrated  with  pus.  A  small  calculus. 
Fever's  patches  in  stage  of  cicatrization.  Author  says  he  cannot 
explain  this  point  of  suppurative  election. 

"Case  10.  L.  Colin.4  Soldier;  end  of  third  week  of  rather 
mild  attack ;  jaundice,  gastro-abdominal  pain.  Death  eleven 
days  later.  Autopsy :  peritonitis  limited  by  transverse  colon, 
liver,  and  abdominal  wall.  Gall-bladder  size  of  goose-egg ;  per- 
forated. Xo  gallstones.  Ducts  pervious.  Typical  intestinal 
lesions. 

"Case  11.  C.  E.  E.  Hoffmann.5  Female,  aged  twenty-five 
years,  jaundice  sixth  week ;  eighth  week,  sinuses  discharging 
through  abdominal  wall.  Death  twelfth  week.  Autopsy  :  de- 
struction of  gall-bladder.  Abscess  beneath  liver  containing  twelve 
gallstones.     Lesions  of  typhoid. 

1  Bull,  de  la  Soc.  Anat.,  1852,  p.  90. 

2  Maladies  des  Enfants,  1853,  2d  edition,  vol.  ii.  pp.  5,  701. 

3  Bull,  de  la  Soc.  Anat.  de  Paris,  1863,  2d  series,  tome  viii.  p.  432. 

4  Etudes  Clin,  de  Med.  Militaire,  Paris,  1864,  p.  197. 

5  Zerstorung  der  G-allenblase  bei  Typhus.  Virchow's  Archiv,  1868,  slii.  219- 
222. 


COMPLICATIONS  DURING  CONVALESCENCE.  217 

"Case  12.  O.  W.  Foot.1  Female,  aged  thirty-two  years.  Died 
in  eighth  week.  Small  abscess  between  coats  of  gall-bladder  com- 
municating by  a  narrow  orifice  with  interior.  Extensive  adhesions 
of  abdominal  wall.     One  cholesterin  calculus,  twenty-three  grains. 

"Case  13.  Burger.2  Man,  aged  forty-one  years.  Twelfth  day. 
pain,  and  tumor  size  of  apple  in  region  of  gall-bladder ;  gradual 
increase  in  size  ;  chills;  no  jaundice.  Death  from  peritonitis  in 
fifth  week.  Perforation  of  gall-bladder.  Adhesions  forming 
cavity  filled  with  pus.     No  gallstones ;  no  abscess  of  liver. 

"  Case  14.  P.  L.  Legendre.3  Female,  aged  thirty  years.  In 
second  week  peritonitis  at  right  upper  abdomen.  Death  twelve 
days  later.  Autopsy  :  perforation  of  gall-bladder.  Pus  in  peri- 
toneal cavity.     Three  gallstones." 

Mason  also  gives  the  following  references  not  already  quoted  in 
footnotes : 

Medical  and  Surgical  i£epo?'fe  of  the  Boston  City  Hospital,  third 
series,  1882. 

Budd,  George  :  On  Diseases  of  the  Liver,  third  American  edition, 
Philadelphia,  1857. 

Harley,  John  :  Article  on  "  Typhoid  Fever,"  Reynolds'  System 
of  Medicine,  vol.  i. 

Pepper,  William  :  American  Journal  of  the  Medical  Sciences, 
January,  1857. 

Guarnieri :  "  Contribute  alia  Patogenesi  della  Infezione  Biliari." 
Ref.  Baumgarten's  Jahresbericht,  1892,  S.  234. 

Chiari,  H.  :  "  Uber  Cholecystitis  Typhosa."  Prag.med.  Woch., 
1893,  No.  22. 

Chiari,  H.  :  "  Uber  das  Vorkommen  von  Typhus  Bacillen  in 
der  Gallenblase  bei  Typhus  Abdominalis,"  Eleventh  International 
Medical  Congress  in  Rome.  Zeitschrift  fur  Ueitkunde,  1894,  Band 
xv.  S.  199. 

1  Enteric  Fever.  Abscess  in  Walls  of  Gall-bladder.  Irish  Hosp.  Gaz.,  Dublin, 
1874,  ii. 

2  Typhus  Abdom.  mit  Perforat.  der  Gallenblase  in  die  Bursa  Omentalis. 
Deutsches  Archiv.  fiir  klin.  Med.,  Leipzig,  1873-74,  xii.  S.  623-630. 

*  Bull,  de  la  Soc.  Anat.  de  Paris,  1881,  4th  series,  tome  vi.  p.  193. 


218     COMPLICATIONS  AND  SEQUEL  JE  OF  TYPHOID  FEVER. 

Letieime  :  "  Recherche  Bacteriologique  sur  la  Bile  Humaine." 
Archives  de  Med.      Experiment,  1891. 

Naunyn  :    Cholelithiasis,  Leipzig,  1892. 

Pisenti :  Archiv  fur  JExper.  path.  Med.  et  Pharm.,  1886.  Ref. 
Brockbank  on  Gallstones,  Philadelphia,  1896. 

Sherrington  :  "  Experiments  on  the  Escape  of  Bacteria  with 
the  Secretions."     Journal  of  Pathology  and  Bacteriology,  1893. 

Blachstein,  A.  G.  :  "  Intravenous  Inoculation  of  Rabbits  with 
Bacillus  Coli  Communis  and  Bacillus  Typhi  Abdominalis."  Bul- 
letin Johns  Hopkins  Hospital,  July,  1891,  vol.  ii.,  No.  14. 

Flexner  :  "  Certain  Forms  of  Infection  in  Typhoid  Fever." 
Johns  Hopkins  Hospital  Reports,  vol.  v. 

Robson,  Mayo  :  "  Diseases  of  the  Gall-bladder  and  Bile-ducts." 
British  Medical  Journal,  March  13,  1897. 

Brockbank  :  Op.  cit.,  p.  130. 

Robson,  Mayo  :  Loc.  cit. 

Monier- Williams  and  Sheild  :  Lancet,  March  2  ,1895. 

Malvoz :  Recherche  Bacteriologique  sur  la  Fievre  Typhoide. 
Paris  et  Leipzig.  Dupre  :  Op.  cit.  Dufort :  Loc.  cit.  Guni- 
precht :  Deutsche  med.  Woch.,  1895,  No.  14,  et  seq. 

Von  Hoffmann  :  Untersuchungen  iiber  die  Pathologisch-anato- 
mischen  Veranderungen  der  Organe  beim  Abdominal-typhus.  Leip- 
zig, 1869. 

Sometimes  in  typhoid  fever  the  mesenteric  and  retroperitoneal 
glands  undergo  suppuration  and  break  down,  causing  sepsis.  In 
other  instances  a  subdiaphragamtic  abscess  forms  because  of  cho- 
lecystitis, of  suppuration  of  these  glands,  or  from  perforation  of 
the  bowel.  A  case  of  this  character  is  recorded  by  Klein1  of  left- 
sided  subphrenic  abscess  due  to  typhoid  fever,  in  which  the  pus 
contained  the  specific  bacillus.  Three  litres  of  pus  were  allowed 
to  escape  by  incision.  The  patient  recovered.  Keen  tells  us  that 
this  is  the  only  case  he  could  find  in  literature. 

1  Uber  die  Pyogene  Wirking  des  Eberthschen  Bacillus  bei  Typhuskornplica- 
tionen.  Inaug.  Dissert.,  Bonn,  1898. 


COMPLICA TIONS  D  URING  CONVALESCENCE.  219 

Tuugol1  reports  a  very  interesting;  case  in  which  a  suppurating 
mesenteric  gland  near  the  caecum  caused  perforation  of  the  supe- 
rior mesenteric  artery  and  death  from  hemorrhage. 

Lehman2  records  a  case  of  suppurating  mesenteric  gland,  the 
pus  of  which  contained  the  bacillus  of  Eberth,  and  FrankeP 
reports  a  case  of  abscess  in  the  abdomen  due  to  this  cause  four 
and  a  half  months  after  the  fever.  The  specific  bacillus  was 
found  in  this  pus  also. 

Other  cases  have  been  reported  by  Michie,4  Thomson,5  and 
Low.6 

Jaundice  complicating  typhoid  fever  is  exceedingly  rare.  Lie- 
bermeister  met  with  it  twenty  times  in  1420  cases,  Griesinger  ten 
times  in  600  cases,  Osier  not  once  in  one  series  of  500  cases. 
Murchison  only  saw  three  cases,  all  of  which  were  fatal.  It  is 
caused  by  catarrh  of  the  ducts,  toxaemia,  abscess  and  gallstones 
Avith  or  without  cholangitis.  Osier,7  however,  records  two  cases, 
in  one  of  which  the  jaundice  developed  at  the  onset  of  a  relapse, 
in  the  other  at  the  end  of  the  second  week.  The  first  case  recov- 
ered, the  second  died  of  toxaemia .  Another  case  of  Jaccoud's, 
studied  by  Sabourin,8  was  that  of  a  man  of  twenty-nine  years,  in 
the  third  week  of  the  disease,  who  had  intense  icterus,  great  asthe- 
nia and  delirium.  Death  ensued,  and  at  the  autopsy  the  lesions  of 
typhoid  fever  were  found  associated  with  a  condition  of  the  liver 
resembling  acute  yellow  atrophy  of  this  organ. 

In  the  tropics  jaundice  seems  to  be  a  more  frequent  complica- 
tion of  typhoid  fever  than  in  the  temperate  zone,  for  Jamieson9 
records  nine  cases,  of  which  four  died. 

Sometimes  hypertrophic  enlargement  of  the  spleen  occurs  after 

1  Klin.  Mittheil  ausder  Kaiserlich.  Hamburg  Allegemeine  Krankenhaus,  1864. 

2  Centralblatt  fiir  klin.  Med.,  August,  1891,  649. 

3  Verhandl.  Kongress  fiir  inner  Med.,  1887,  179. 
*  British  Medical  Journal,  1888,  i.  1388. 

5  Glasgow  Medical  Journal,  1882,  xvii.  244. 

6  British  Medical  Journal,  1881,  ii.  122.  "  Loc.  cit. 

8  Bevue  de  Med.,  1882,  vol.  ii.  p  IJOO. 

9  Imperial  Maritime  Customs  Med.  Beports,  1891,  37th  issue. 


220     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

typhoid  fever.     I  have  seen  two  cases ;  one  is  under  my  care  at 
present,  the  other  was  some  years  ago,  and  is  shown  in  Fig.  20. 

A  number  of  cases  of  rupture  of  the  spleen  due  to  the  devel- 
opment of  an  abscess  and  later  exposure  and  traumatism  have 
been  recorded  during  convalescence  in  typhoid  fever.  A  case  of 
rupture  of  the  spleen,  uot  due  to  these  causes  is,  however,  reported 

Fig.  20. 


Splenic  enlargement  after  typhoid  fever. 

by  Santi  Flavio,1  in  a  man  of  twenty  years,  after  having  been 
under  observation  for  ten  days,  suffering  from  typhoid  fever,  devel- 
oped pleural  pneumonia  with  pleural  effusion,  which  required  tap- 
ping. Two  months  later  the  patient  suffered  from  severe  pain  in 
the  left  hypochondrium,  the  action  of  the  heart  became  rapid  and 
feeble,  and  oedema  of  the  left  leg  was  present.     After  a  brief 

1  Gazetta  degli  Ospitali,  1S91,  No.  43. 


COMPLICATIONS  DURING  CONVALESCENCE.  221 

period  of  improvement  the  patient  was  suddenly  seized  with  peri- 
tonitis and  died,  and  the  autopsy  showed  that  in  addition  to  the 
peritonitis  there  had  been  rupture  of  the  spleen,  and  that  the  pus 
which  it  contained  had  been  diffused  throughout  the  entire  perito- 
neal cavity.  A  recent  infarction  was  found  in  the  neighborhood 
of  the  rupture,  and  the  intestines  showed  evidences  of  an  old 
typhoid  fever. 

As  an  interesting  illustration  of  what  a  patient  may  recover 
from  during  typhoid  fever  in  the  way  of  an  accident  extrinsic  to 
his  disease,  a  case  is  recorded  by  Heath,1  of  a  man  of  twenty-three 
years,  who  at  the  end  of  the  fourth  week  of  his  fever  swallowed 
the  clinical  thermometer  which  the  nurse  had  placed  in  his  mouth. 

A  mustard  emetic  failed  to  bring  away  the  thermometer,  nor 
did  a  castor-oil  purge  cause  its  discharge  from  the  bowel,  but 
twelve  days  after  it  had  been  swallowed  it  was  passed  unbroken 
and  registered  a  temperature  of  104.7°. 

Nervous  Symptoms  in  the  Far-advanced  Stage  of  the  Dis- 
ease or  Following  Typhoid  Fever.  Paralysis  complicating 
typhoid  fever  or  its  convalescence  may  occur  in  a  number  of 
forms,  just  as  paralysis  may  occur  from  lesions  due  to  other  causes. 

It  may  occur  as  a  local  paralysis  or  monoplegia,  as  a  general 
paralysis,  as  a  paraplegia,  or  as  a  hemiplegia,  and  it  may  be  due 
in  the  first  three  instances  to  peripheral  neuritis,  in  the  second 
instance  to  a  myelitis  or  neuritis,  and  in  the  case  of  hemiplegia  to 
cerebral  lesions,  such  as  thrombosis,  embolism,  hemorrhage,  and 
meningoencephalitis.  Sometimes  the  monoplegia  or  partial  para- 
plegia may  be  due  to  a  poliomyelitis. 

By  far  the  most  common  of  these  affections  is  the  loss  of  power 
due  to  neuritis,  a  condition  which  is  not  commonly  met  with  as  a 
complication  of  typhoid  fever,  yet  not  so  rare  as  the  other  changes 
just  named.  The  most  exhaustive  and  interesting  monograph  con- 
cerning this  complication  of  the  disease  is  that  given  us  by  Ross 
and  Bury,2  in  their  essay  on  "  Peripheral  Neuritis,"  first  published 

1  American  Lancet,  December,  1888. 

2  A  Treatise  on  Peripheral  Neuritis.     Griffin  &  Co.,  1893. 


222     COMPLICATIONS  AND  SEQUELM  OF  TYPHOID  FEVER. 

in  the  Medical  Chronicle  and  afterward  in  a  separate  volume.  So 
complete  and  thorough  is  their  study  of  the  literature  of  the  sub- 
ject and  of  the  clinical  aspect  of  the  condition  that  much  of  the 
following  information  is  to  be  credited  to  them. 

Gubler,1  among  several  cases  of  local  palsy  after  typhoid  fever, 
records  the  case  of  a  boy  of  sixteen  years,  who  developed,  a  few 
days  after  his  fever  ceased,  a  nasal  voice,  which  was  found  to 
depend  upon  paralysis  of  the  palate.  Shortly  after  this  there  was 
paralysis  of  accommodation.  This  latter  point  is  of  interest  in 
view  of  the  fact  that  Gowers  states  that  this  condition  never  arises 
from  typhoid  fever.  Gubler  also  states  the  case  of  a  boy  who,  after 
an  attack  of  forty-seven  days,  suffered  from  paresis  in  his  legs  and 
became  unable  to  raise  himself  in  bed.  His  lower  limbs  were 
feeble,  tremulous  and  their  muscular  irritability  greatly  increased. 
There  was  also  loss  of  power  in  the  hands  with  some  spastic  con- 
traction of  the  fingers,  and  the  speech  was  staccato. 

Surmay2  records  two  cases  of  local  paralysis  due  to  this  cause. 
In  one  the  loss  of  power  was  in  the  extensor  muscles  of  the  hand 
and  fingers  and  in  the  extensors  of  the  toes,  and  in  the  other  case, 
weakness  of  the  right  leg  was  followed  by  complete  loss  of  power 
in  the  left.  So,  too,  Kraft-Ebing3  speaks  of  weakness  of  the 
adductors  of  the  thigh  and  hyperesthesia  of  the  skin  supplied  by 
the  saphenous  nerve.  Bailly4  has  recorded  paraplegia,  anaesthesia, 
and  contractions  in  these  cases,  and  in  two  instances  paralysis  of 
the  palate,  and  Nothnagel0  records  four  patients  in  whom  the 
ulnar  nerves  were  paralyzed  and  the  ulnar  side  of  the  hand  was 
anaesthetic.  In  all  these  cases  there  was  the  reaction  of  degenera- 
tion, and  they  also  suffered  from  radiating  pains  in  the  upper  and 
lower  extremities.  In  four  other  cases  there  was  partial  paralysis 
of  the  lower  limbs  with  partial  anaesthesia,  pain,  and  tingling  sen- 
sations, and  in  one  of   these  patients  the  trouble  in   the  lower 

1  Gubler.     Arch.  General  de  Med.,  1860. 

2  Surmay.     Arch.  General  de  Med.,  1865,  tome  i.  p.  678. 

3  Kraft-Ebing.  Beobachtungen  und  Erfahrungen   iiber  Typhus  Abdominalis, 
1871. 

4  Bailly.     These  de  Paris,  1872. 

0  Nothnagel.     Deutsches  Arch,  fur  klin.  Med.,  Bd.  ix.  p.  429. 


COMPLICA  TIONS  D  URING  CON VA  LESCENCE.  9 23 

extremities  was  folloAved  by  weakness  in  the  upper  limbs.  In  still 
another  the  patient  at  the  beginning  of  convalescence  first  had  a 
feeling  of  numbness  and  creeping  in  the  left  leg,  and  after  this, 
paralysis  of  that  limb  gradually  developed.  Later  on  the  exten- 
sors of  the  right  hand  became  paralyzed,  and  four  days  later  some 
of  the  muscles  of  the  left  hand. 

Similar  cases  have  been  reported  by  Leyden1  and  Benedict,  and 
in  one  recorded  by  Eisenlohr,2  a  man  of  thirty  years,  eleven  days 
after  his  temperature  became  normal,  suffered  from  numbness  and 
loss  of  power  in  the  left  leg  and  feet,  with  violent  pain  in  these 
parts  and  in  both  knees,  followed  the  next  day  by  effusion  into 
the  right  knee  and  a  rise  of  temperature  to  104°.  There  was 
loss  of  power  in  the  left  peroneal  nerve,  and  fourteen  days  later 
the  left  knee  became  swollen.  On  the  sixteenth  day  the  right 
elbow  became  swollen  and  painful  and  the  swelling  of  the  left 
knee  subsided.  The  muscles  supplied  by  the  left  peroneal  nerve 
showed  diminished  reaction,  and  the  left  foot  was  cedematous  and 
in  the  position  of  equino  varus.  On  the  twenty-fourth  day  the 
flexors  of  the  feet  and  the  extensors  of  the  toe  were  completely 
paralyzed,  and  gave  the  reaction  of  degeneration. 

This  case  of  Eisenlohr's  is  of  interest,  first  because  the  swelling 
passing  from  joint  to  joint  might  hav,e  aroused  a  suspicion  that  the 
cause  was  rheumatic,  and  because  certain  writers  in  quoting  the 
case  considered  it  as  an  instance  of  paralysis  coming  on  during 
relapse.  As  Ross  and  Bury  point  out,  it  is  possible  that  the  rheu- 
matic poison  was  the  cause  of  both  the  joint  changes  and  the 
evidences  of  neuritis. 

Additional  cases  of  peripheral  neuritis  have  also  been  reported 
by  Bernhardt,3  Vulpian,  and  others.  Thus  a  case  of  deltoid  paral- 
ysis has  been  recorded  by  Vulpian,1  which  was  in  all  probability 
due  to  a  peripheral  neuritis.  A  young  man  of  eighteen  years, 
after  an  attack  of  typhoid  fever,  suffered  from   pain   in   the  arm 

1  Leyden.     Klinik  de  Ruckenmarkskrankheiten,  1875,  Bd.  ii.  Abth.  1,  p.  247. 

2  Eisenlohr.    Arch,  fur  Psychiatrie  und  Nervenkrankheiten,  187(5,  Bd.  vi.  p.  543. 

3  Bernhardt.     Deutsch.  Arch,  fur  klin.  Med.,  1878,  p.  363. 

4  D'Accident  Survenus  Pendant  la  Convalescence  de  la  Fifivre  Typhoide. 
Revue  de  Medicine,  1883,  p.  617. 


224     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

and  developed  loss  of  power  in  the  right  shoulder,  with  atrophy  of 
the  deltoid  muscle.  In  none  of  these  cases,  however,  were  any 
studies  made,  over  and  above  the  clinical  tests  which  are  ordinarily 
employed,  to  prove  positively  that  a  true  neuritis  was  present,  and 
it  was  not  until  Pitres  and  Vaillard1  published  their  paper,  in  1885, 
that  the  first  careful  microscopical  observations  upon  typhoid 
peripheral  neuritis  were  presented.  After  detailing  the  cases  of 
two  patients  who  suffered  from  typhoid  neuritis  they  give  the 
results  of  the  histological  examination  of  nerves  removed  from 
the  bodies  of  four  patients  who  died  during  the  active  period  of 
typhoid  infection,  but  in  Avhom  no  signs  of  peripheral  neuritis  had 
been  noted  during  life.  Curiously  enough,  in  three  out  of  these 
four  cases  changes  indicating  parenchymatous  neuritis  were  found 
to  be  present,  and,  still  more  curiously,  one  of  these  patients  died 
as  early  as  the  sixteenth  day  of  the  disease,  while  two  others  died 
on  the  thirty-sixth  and  twenty-fourth  days  respectively. 

Other  instances  of  post-mortem  examinations  revealing  periph- 
eral neuritis  in  typhoid  fever  are  those  reported  by  Oppenheim 
and  Siemerling.  In  one  of  these  instances  the  patient  died  in  the 
middle  and  the  other  at  the  end  of  the  second  week  of  the  fever, 
and  in  both  cases  parenchymatous  degeneration  of  the  peripheral 
nerves  was  found,  in  one  of  which  it  affected  the  great  saphenous 
and  peripheral  nerves,  and  hi  the  other  a  branch  of  the  cutaneous 
nerve  supplying  the  dorsum  of  the  right  foot,  and  showed  com- 
plete degeneration  of  many  of  its  fibres. 

Since  these  papers  have  been  published,  others  dealing  with 
the  clinical  aspect  of  the  case  have  been  placed  upon  record  by 
Alexander,2  Handford,3  Archer,4  Humphreys,5  Klumpke-Dejerme,6 

1  Pitres  and  Vaillard.  Compte  Rendu.  Soc.  de  Biol.,  Paris,  1885,  S.  8,  ii. 
661,  and  Eev.  de  Med.,  Paris,  1885,  v.  985. 

2  Alexander.      Deutsche  med.  Wochenschrift,  1886,  vol.  xii.  529. 

3  Handford,  H.     Peripheral  Neuritis  in  Enteric  Fever.     Brain,  vol.  xi.  237. 
*  Archer.     British  Medical  Journal,  1887,  vol.  i.  p.  727. 

5  Humphreys  (F.  R. ).  A  Case  of  Peripheral  Neuritis  following  Typhoid 
Fever.     Abstr.  Tr.  Hunterian  Society,  London,  1889-90,  41. 

6  Dejerine-Klumpke.  Des  Polynevrites  en  General  et  des  Paralysies  et  Atro- 
phies Saturnines  en  Particulier.     Paris,  1889,  p.  222. 


COMPLICATIONS  DURING  CONVALESCENCE.  225 

and  notably  the  two  cases  reported  by  Bury  in  the  essay  which  I 
have  named.  One  of  these  was  in  a  girl  of  eighteen  years,  who 
was  seen  eight  months  after  an  attack  of  typhoid  fever  of  varied 
duration  and  severity.  During  the  fever  she  was  suddenly  affected 
by  a  condition  in  which  she  was  unable  to  straighten  out  her 
upper  and  lower  limbs,  and  this  rigidity  persisted  until  she  was 
admitted  to  the  Manchester  Royal  Infirmary,  eight  months  after- 
ward, when  it  was  found  there  was  great  wasting  of  all  the  mus- 
cles of  the  limbs,  particularly  in  the  muscles  on  the  front  of  the 
thigh  and  outer  part  of  the  legs.  There  was  drooping  of  the 
great  toes  and  the  knee-jerks  were  variable,  sometimes  being 
excessive  and  sometimes  being  minus.  The  plantar  reflexes  were 
absent,  and  there  was  no  ankle-clonus.  The  upper  limbs  were 
somewhat  flexed,  and  could  not  be  extended,  and  there  was  atrophy 
of  the  thenar  and  hypothenar  eminences  ;  there  were  also  marked 
disorders  in  cutaneous  sensibility  in  the  distribution  of  the  radial 
nerve.  The  contractions  could  not  be  overcome  even  when  the 
patient  was  put  under  chloroform,  and  while  the  paralysis  and 
rigidity  remained  for  many  weeks,  the  patient  ultimately  made  a 
complete  recovery. 

In  still  another  case,  long  after  typhoid  fever,  a  man  of  forty- 
two  years,  suffered  from  pains  in  his  legs,  in  which  all  the  muscles 
below  the  knees  presented  a  moderate  degree  of  wasting ;  he  had 
exaggerated  knee-jerks. 

Dercum  has  reported  to  the  author  two  cases  of  peripheral  neu- 
ritis after  typhoid  fever,  due  to  the  excessive  administration  of 
alcohol  during  the  illness.  Thus  a  girl  of  fourteen  years  received 
one  and  a  half  pints  a  day  for  some  time,  and  developed  typical 
alcoholic  neuritis. 

These  cases  give  some  idea  of  the  character  of  the  various  forms 
of  peripheral  neuritis  which  follow  typhoid  fever.  Other  instances 
might  be  quoted  in  which  there  was  doubt  as  to  whether  paraplegic 
symptoms  were  due  to  neuritis  or  to  damaged  tone  of  the  tracts 
and  cells  in  the  spinal  cord.     Thus  Mitchell1  has  recorded  a  case 

1  Mitchell  (S.  W. ).     Boston  Medical  and  Surgical  Journal,  1879,  c.  245. 

15 


226     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

of  paraplegia  associated  with  tremor,  in  which  he  thought  that  the 
paralysis  was  due  to  degeneration  of  the  cells  in  the  anterior  cor- 
nua  of  the  spinal  cord,  but  Ross  and  Bury  consider  that  the  rapid 
improvement  of  this  patient  indicated  that  she  was  suffering  rather 
from  a  peripheral  than  a  spinal  disease.  So,  too,  George  Ross1 
has  recorded  a  case  in  which  there  was  paralysis  with  spastic  con- 
traction of  the  lower  extremities,  with  loss  of  electrical  reaction, 
but  no  diminution  in  the  abilities  of  the  sphincters,  and  in  which 
complete  recovery  took  place. 

That  severe  peripheral  neuritis  may  result  in  trophic  changes  in 
the  organs  supplied  by  the  nerves  which  are  involved  is  shown  by 
a  case  reported  by  Wedenski,2  of  a  boy  of  seventeen  years,  in 
whom,  two  years  after  typhoid,  symmetrical  gangrene  developed  as 
a  result  of  degeneration  of  the  peripheral  nerves.  !No  lesions 
were  found  in  the  muscles  nor  in  the  cerebro-spinal  nervous 
system. 

Closely  associated  with  the  question  of  true  paraplegia  follow- 
ing enteric  fever  is  that  partial  paraplegia  or  ataxia  of  the  stage 
of  convalescence  in  which  there  is  a  strange  inability  of  the  patient 
to  use  his  lower  limbs.  This  lasts  in  nearly  all  severe  cases  for  some 
days  after  the  patient  leaves  his  bed,  and  is  often  persistent  for 
some  weeks,  causing  a  peculiar  waddle  or  stiff -legged  gait  quite 
pathognomonic  of  this  state. 

In  connection  with  the  question  as  to  whether  these  various 
forms  of  paralysis  are  spinal  or  peripheral,  the  following  quotation 
from  Ross  and  Bury  is  of  importance  : 

"While  it  is  probable  that  a  few  cases  of  muscular  atrophy 
which  follow  typhoid  fever  depend  upon  an  anterior  poliomyelitis, 
and  that  a  condition  similar  to  that  of  infantile  paralysis  is  pro- 
duced, the  presence  of  sensory  disturbances  in  the  vast  majority 
of  cases  shows  that  the  lesion,  if  in  the  cord  at  all,  is  not  limited 
to  the  anterior  horns,  or  involves  both  the  anterior  and  posterior 
roots,  or  the  mixed   peripheral   nerves.     The   absence  of    spinal 

1  Eoss  (G. ).     International  Journal  of  the  Medical  Sciences,  1889,  p.  25. 

2  Wiener  Medizinischer  Presse. 


COMPLICATIONS  DURING  CONVALESCENCE.  227 

tenderness,  of  girdle  pains,  and  of  disturbances  of  the  sphincters 
speaks  much  against  an  infection  of  the  spinal  cord  or  its  roots, 
while  the  initial  sensory  disturbance,  succeeded  by  a  limited  paral- 
ysis having  a  slow  progressive  march  up  to  a  certain  degree,  which 
varies  according  to  the  severity  of  the  case,  the  paralysis  then 
slowly  receding  and  ultimately,  as  a  rule,  completely  disappear- 
ing, are  points  strongly  in  favor  of  an  affection  of  the  peripheral 
nerves." 

An  interesting  case  of  peripheral  neuritis  after  typhoid  fever 
has  been  recorded  by  Putnam,  of  Boston.  In  this  the  patient 
suffered  from  trophic  changes  in  that  small  abrasions  did  not  heal. 
There  was  marked  analgesia,  and  when  seen  two  years  after  the 
attack  of  the  fever,  this  disturbance  of  sensation  extended  to  the 
left  arm  and  shoulder,  the  left  side  of  the  neck  and  trunk  as  far  as 
the  eighth  rib.     Marked  improvement  followed  treatment. 

There  are  three  other  classes  of  symptoms  showing  peripheral- 
nerve  disturbances  :  First,  cases  in  which  excessive  muscular  con- 
tractions are  developed  in  place  of  paralysis,  but  associated  with 
pain  and  hyperesthesia.  Eleven  of  these  cases  have  been  reported 
by  Aran  in  U  Union  Ifedicale,  July,  18,  1855.  The  contractions 
occurred  toward  the  end  of  the  attack  of  typhoid  fever,  and  never 
were  begun  with  the  commencement  of  the  disease.  They  were 
preceded  by  formication,  prickings,  and  numbness  in  the  extremi- 
ties, and  pain  in  the  joints,  and  the  immediate  seizure  was  associated 
with  an  intense  feeling  of  anxiety  and  distress,  the  contractions 
affecting  both  upper  and  lower  limbs,  so  that  many  muscles  exhib- 
ited almost  incessant  fibrillary  contractions.  By  gradual  manipu- 
lation, artificial  extension  could  be  obtained,  and  this  gave  the 
patient  relief  for  a  short  time.  In  four  cases  the  muscles  of  the 
trunk  were  affected  and  opisthotonus  was  produced,  the  patient 
being  held  immovable  by  the  muscular  contraction,  which  also 
caused  great  pain.  These  attacks  lasted  from  a  quarter  of  an  hour 
to  three  hours  and  recurred  from  two  to  ten  times  a  day,  and  after 
the  cessation  of  the  attacks  the  fever  ran  its  ordinary  course  with- 
out any  other  symptoms  save  an  occasional  numbness  of  the 
affected  parts.     Although  three  of  the  patients  died,  Aran  thinks 


228     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

their  deaths  were  due  to  the  severity  of  the  fever  and  not  to  the 
tetanic  complication.  These  cases  so  closely  resemble  tetanus  that 
similar  ones  could  be  readily  taken  for  tetanus  if  the  symptoms 
occurred  early  in  the  course  of  typhoid  fever. 

Gubler1  has  recorded  a  case  of  contraction  of  the  hands,  and 
Dewerve  refers  to  this  condition  as  possible  of  occurrence  in  the 
Nouveau  Dictionnaire  de  Ife'dicine  et  de  Chirurgie.  So,  too,  ISoth- 
nagel2  refers  to  a  case  of  tonic  contractions  of  the  interosseous 
muscles  lasting  from  one-quarter  to  one-half  an  hour.  Similar 
contractions  ensued  when  the  patient  supported  himself  on  his 
toes. 

A  second  class  of  nervous  disturbances  is  closely  associated 
with  the  general  signs  of  peripheral  neuritis,  and  is  thought  by 
some  to  have  become  more  frequent  since  the  general  introduction 
of  the  cold  bath  in  the  treatment  of  typhoid  fever.  These  signs 
have  been  particularly  described  by  Handf  ord,  and  consist  of  great 
hyperesthesia  of  the  toes  and  heels  of  patients  in  the  latter  part 
of  the  disease  or,  more  particularly,  during  convalescence. 

Finally,  a  few  cases  have  been  recorded  in  which  the  rapidly 
ascending  paralysis,  usually  terminating  fatally,  has  occurred 
during  the  course  of,  or  immediately  after,  an  attack  of  typhoid 
fever. 

Cases  of  myelitis  or  anterior  poliomyelitis,  as  a  result  of  typhoid 
fever  are  so  rare  as  to  be  almost  unknown,  although  Gowers,  as 
already  quoted,  has  stated  that  poliomyelitis  is  more  frequently 
secondary  to  typhoid  fever  than  to  any  other  acute  infectious 
disease. 

Two  cases  of  ascending  myelitis  are  recorded  by  Raymond  in 
La  Science  de  MSdieine  for  1885,  but  in  each  of  these  there  is  good 
reason  to  believe  that  the  lesions  were  really  those  of  neuritis  and 
not  really  those  of  myelitis.  A  case  has,  however,  been  reported 
by  Shore  in  the  St.  Bartholomeiv's  Hospital  Reports,  vol.  xxiii.,  in 
which  there  was  acute  myelitis  of  the  anterior  cornua  and  involve- 
ment of  three  of  the  eight  cervical  nerves. 

1  Archives  Generate  de  Me"d.  xv.  5th  series. 

2  Deutsche  Arch,  fur  klin.  Med.,  1872,  9. 


COMPLICATIONS  DURING  CONVALESCENCE.  229 

Hemiplegia  arising  from  typhoid  fever  is  not  as  rare  as  mye- 
litis, and  is  far  less  common  than  paralysis  due  to  peripheral  neu- 
ritis. By  far  the  most  extensive  research  into  the  literature  of 
this  subject  is  that  of  Dr.  Francis  Hawkins,  who  has  collected  in 
the  Clinical  Society*  Transactions  for  1893,  vol.  xxvi.,  17  cases 
from  literature  ;  3  of  these  occurred  in  children  under  fifteen  years 
of  age,  and  the  time  of  onset  in  14  of  the  cases  was  the  second 
week ;  in  1  case  the  third  week ;  in  6  cases  the  fourth  week,  and 
in  5  cases  during  convalescence.  The  right  side  was  paralyzed  in 
12  of  the  16  cases  in  which  the  statement  as  to  the  side  paralyzed 
was  given,  and  aphasia  occurred  iu  twelve  instances.  Curiously 
enough,  only  two  of  the  seventeen  cases  died,  and  in  both  of 
these  a  thrombus  plugged  the  middle  cerebral  artery.  In  all  prob- 
ability a  great  majority  of  the  cases  of  hemiplegia  complicating 
typhoid  fever  are  due  to  this  lesion.  Thus,  Osier  has  recorded  a 
case  of  a  young  physician  who  was  taken  ill  with  typhoid  fever,  on 
the  fourteenth  day  had  a  temperature  of  104°,  which,  however, 
fell  the  following  morning  to  100.7°,  and  in  the  next  three  or 
four  days  the  temperature  had  not  reached  102.5°  when  the  rash 
developed  and  the  spleen  became  palpable.  Twenty-four  hours 
later,  when  all  the  symptoms  of  the  case  seemed  favorable,  he  was 
suddenly  seized  with  uneasy  feelings  in  his  head,  the  pupils  were 
dilated,  and  in  a  few  minutes  he  suffered  from  a  short,  sharp  gen- 
eral clonic  convulsion,  beginning  almost  simultaneously  in  both 
arms  ;  the  eyes  showed  marked  conjugate  deviation  to  the  left  and 
upward,  and  the  head  was  also  turned  to  the  left.  The  convul- 
sions were  profound  at  short  intervals  for  an  hour,  then  became 
less  intense,  and  finally  ceased  altogether  for  several  hours ;  they 
were  accompanied  by  profound  unconsciousness,  and  the  severer 
ones  occasioned  great  embarrassment  to  the  respiration.  In  the 
interval  the  patient  was  conscious,  spoke  to  those  about  him,  and 
seemed  to  understand  questions.  Later  in  the  evening  the  con- 
vulsions recurred  with  great  severity,  and  after  five  hours  the 
patient  died  in  a  severe  one.  These  convulsions  were  general,  but 
were  most  marked  on  the  right  side  of  the  body.  A  post-mortem 
examination  held  by  Flexner  revealed  thrombosis  in  the  ascending 


230     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

parietal  and  parietotemporal  branches  of  the  middle  cerebral 
artery.  The  meninges  over  these  vessels  contained  small  hemor- 
rhages, and  the  brain-matter,  while  not  softened,  showed  small 
extravasations  of  blood.  Small  but  quite  extensive  punctiform 
hemorrhages  could  be  seen  to  occupy  the  cortex  and  adjacent  white 
substance  in  the  immediate  neighborhood  of  the  thrombosed  ves- 
sels. 

Out  of  the  well-known  120  cases  collected  by  William  Osier  of 
hemiplegia  in  children  there  was  no  instance  of  hemiplegia  fol- 
lowing typhoid  fever,  and  in  160  cases  collected  by  "Wallenberg, 
four  only  occurred  after  typhoid  fever.  Osier,1  however,  reports 
two  cases  of  post-typhoid  hemiplegia.  One  of  these  occurred  in 
a  girl  of  six  years.  Almost  two  months  after  the  beginning  of 
her  illness  she  was  seized  with  violent  convulsions,  which  were 
confined  to  the  head,  right  arm  and  leg ;  she  became  unconscious. 
Later  it  was  noticed  that  the  right  side  was  completely  paralyzed, 
including  the  face,  and  that  there  was  total  loss  of  speech  and  apha- 
sia, lasting  for  seven  weeks.  Gradually  the  patient  largely  recov- 
ered from  this  paralysis,  but  complete  recovery  did  not  ensue. 
The  second  case  was  that  of  a  clergyman,  aged  twenty-five  years, 
who  was  seized  with  convulsions  fourteen  days  after  going  to  bed 
with  headache,  fever,  and  diarrhcea.  In  this  case  also  partial 
recovery  took  place,  but  Osier  did  not,  at  the  time  of  making  his 
report,  consider  that  complete  recovery  would  be  possible.  The 
paralyzed  arm,  the  left,  many  months  after  the  attack,  was  affected 
by  wide  irregular  choreiform  movements  on  attempting  any  volun- 
tary effort,  but  his  mental  condition  was  excellent. 

Another  case  of  this  character  was  reported  to  the  Johns  Hop- 
kins Medical  Society  by  Blurner  :2  that  of  a  little  girl  who  one 
week  after  convalescence  had  begun,  and  who  had  been  eating 
solid  food,  was  seized  with  violent  convulsions,  which  were  con- 
fined almost  entirely  to  the  right  side.  These  convulsions  lasted 
for  eight  hours,  and  were  followed  by  paralysis  of  the  right  side ; 


1  Journal  of  Xervous  and  Mental  Diseases,  May,  1896. 

2  Johns  Hopkins  Hospital  Bulletin,  April,  1896,  p.  72. 


COMPLICATIONS  DURING  CONVALESCENCE.  231 

five  weeks  after  the  onset  of  these  convulsions  she  began  to  recover 
both  the  power  to  move  the  arm  and  leg',  and  also  that  of  speech ; 
she  suffered  from  amnesic  aphasia ;  ultimately  almost  complete 
recovery  took  place,  so  that  there  was  only  slight  dragging  of  the 
foot,  and  some  pure  motor  aphasia.  The  arm,  however,  did  not 
materially  improve,  and  was  affected  by  rigid  paralysis,  though  with 
no  sign  of  facial  paralysis,  and  the  tongue  was  protruded  straight. 
Blumer  believed  that  the  case  was  due  to  thrombosis. 

In  the  same  journal  Thayer  records  two  other  cases  of  this 
character  seen  in  the  Massachusetts  General  Hospital.  On  the 
tenth  day  of  the  illness  in  one  case  the  ward  orderly  found  at  1 
a.m.  that  the  patient  was  unable  to  move  the  right  arm  and  leg ; 
the  face  was  flushed,  the  eyes  half  closed,  the  pupils  equal,  and 
eyeballs  rolled  upward.  The  patient's  mental  condition  was  very 
stupid.  Eight  days  later  the  patient  was  distinctly  better,  unable 
to  speak,  but  evidently  understood  what  was  said  to  him ;  he 
could  not  protrude  his  tongue,  but  later  was  able  to  read  the  paper 
and  to  say  a  few  words. 

The  other  case  was  that  of  a  girl  of  ten  years,  admitted  to  the 
Massachusetts  General  Hospital  on  the  fifth  day  of  typhoid  fever, 
who  was  found  on  the  twenty-third  day  of  her  disease  to  lie  prin- 
cipally upon  the  right  side,  and  failed  to  answer  questions.  The 
next  day  the  patient  could  not  speak,  although  she  apparently 
understood  what  was  said  to  her ;  the  tongue  was  protruded 
straight ;  the  face  was  not  paralyzed. 

In  other  words,  these  are  two  cases  illustrating  the  onset  of 
complete  right-side  hemiplegia  with  motor  aphasia. 

A  case  of  hemiplegia  has  also  been  recorded  by  jSTewbolt,1  in 
which  a  locomotive  fireman  of  twenty-one  years  suffered  from 
loss  of  power  in  the  left  arm  and  leg  during  the  course  of  a  relapse. 
There  was  aphasia,  and  the  tongue  was  protruded  to  the  right ; 
there  was  drooping  of  the  right  eyelid,  and  some  dysphagia.  Per- 
fect recovery  did  not  occur.  The  case  was  thought  to  have  been 
due  to  thrombosis. 

1  London  Lancet,  August  27,  1893. 


232     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

Still  another  case  of  hemiplegia  complicating'  typhoid  fever  is 
recorded  by  Imradi.1  The  case  had  been  considered  one  of  influ- 
enza, and  the  patient  was  allowed  to  go  out  on  the  fifteenth  day, 
when  he  suddenly  lost  consciousness  and  remained  unconscious  for 
hours ;  when  seen  he  was  suffering  from  left -sided  hemiplegia. 
The  fever  ran  a  typical  characteristic  course,  but  recovery  occurred. 

Imradi  asserts  that  there  are  only  fifteen  similar  cases  to  be 
foimd  in  literature. 

Vulpian2  has  recorded  a  case  of  obstruction  of  the  left  Sylvian 
artery  in  the  course  of  typhoid  fever,  causing  right  hemiplegia  and 
aphasia  in  a  male  of  seventy  years. 

Under  the  title  of  "A  Case  of  Hemiplegia  of  Gradual  Onset 
Following  a  Severe  Attack  of  Enteric  Fever,  and  Terminating  in 
Insanity"  (which  was  probably  male  hysteria),  Stevens3  has  re- 
corded the  history  of  a  man  of  twenty-two  years  who  three 
months  after  recovery  from  this  disease  found  he  had  difficulty  in 
approximating  the  fingers  of  his  left  hand  to  one  another.  He 
tells  us  that  "  the  fingers  are  flexed  upon  the  palm  of  the  hand 
more  or  less.  They  can  passively  and  slightly,  by  voluntary 
effort,  be  extended  within  narrow  limits  (see  figure  in  Glasgow 
Medical  Journal).  The  thumb  is  turned  outward  and  flexed  at 
the  interphalangeal  joint.  Forcible  extension  of  the  fingers  is 
accompanied  by  considerable  pain,  but  the  thumb  is  less  painful  in 
this  respect.  The  wrist  joint  is  fixed,  evidently  largely  by  mus- 
cular spasm,  and  not  by  definite  anchylosis.  Movement  of  flexing 
the  forearm  on  the  arm  is  perfectly  easily  accomplished,  but  it  is 
accompanied  by  considerable  fine  tremor  of  the  whole  arm.  On 
attempting  to  raise  the  left  arm  above  the  head  it  becomes  evident 
that  there  is  little  movement  at  the  shoulder-joint.  Most  of  the 
movement  is  accomplished  by  moving  the  arm  and  shoulder  en 
masse,  and,  as  a  result  the  range  is  much  more  limited  than  on  the 
other  side.  There  is  no  definite  wasting  of  any  of  the  arm  mus- 
cles.    The  position  of  the  thumb  in  relation  to  the  other  fingers  is 

1  Centralblatt  fur  de  ined.  "Wissenschaften,  October  25,  1891. 

2  Eevue  de  Medicine,  1884,  p.  162. 

3  Glasgow  Medical  Journal.  January  to  July,  1897,  vol.  xlvii. 


COMPLICATIONS  DURING  CONVALESCENCE.  233 

further  noted.  It  is  turned  around  in  such  a  way  that  it  rests 
upon  the  radial  aspect  of  the  first  phalanx  of  the  forefinger.  As 
regards  the  foot,  there  is  noted  a  spastic  condition  evidently  involv- 
ing the  extensors,  so  that  the  toes  are  all  drawn  well  up  upon  the 
dorsum  of  the  foot,  the  first  phalanx  in  each  ease  being  drawn  far 
back  upon  the  metatarsal  bone.  The  extensor  tendons  stand  out 
like  cords.  Despite  this,  movement  of  the  ankle-joint  is  fairly 
free,  although  rather  jerky.  The  power  of  the  muscles  of  the 
thigh,  as  tested  by  making  and  resisting-  movements  of  flexion  and 
extension  of  the  knee,  is  fairly  good  in  both  lower  extremities,  and 
no  appreciable  difference  is  made  out  between  the  two  sides. 

"  Sensation  is  tested  in  both  upper  and  lower  extremities,  and 
found  to  be  normal.  The  reflexes  (tendon)  in  the  left  upper 
extremity  are  abolished  ;  in  the  right,  normal.  The  superficial 
abdominal  and  cremasteric  reflexes  on  the  right  side  are  easily 
elicited ;  the  former  can  be  faintly  brought  out  on  the  left  side, 
but  the  latter  on  the  left  side  cannot  be  elicited.  The  knee  reflex 
is  distinctly  exaggerated  on  the  left  side,  and  the  ankle-clonus  is 
very  marked,  while  on  the  right  side  the  knee  reflex  is  normal, 
and  there  is  no  ankle-clonus." 

Later  the  patient  became  insane  and  passed  into  an  asylum,  and 
the  asylum  physicians  made  the  following  report  on  his  case,  decid- 
ing that  the  condition  was  male  hysteria.     They  state  : 

"  The  points  that  guided  us  in  inclining  to  a  diagnosis  of  the 
hysterical  nature  of  the  case  were  as  follows  : 

"1.  The  varying  intensity  of  the  symptoms.  The  flexion  of 
the  arm  was  not  constant ;  at  times  it  admitted  of  a  limited  move- 
ment and  a  limited  power  of  passive  extension,  but  at  other 
times  the  spasm  of  the  flexors  was  intense,  and  manipulation  was 
almost  consciously  resisted.  The  symptoms  in  the  leg  varied  even 
more  than  in  the  arm. 

"  2.  The  comparative  absence  of  atrophy  of  muscles,  considering 
the  duration  of  his  illness  (since  the  middle  of  1895).  Measure- 
ments taken  last  month  showed  that  while  there  was  a  degree  of 
atrophy  the  greatest  difference  was  between  the  right  and  left 
thighs,  which  was  only  one  and  one-quarter  inch. 


234     COMPLICATIONS  AND  SEQUEL  JE  OF  TYPHOID  FEVER. 

"3.  Apparently  normal  response  of  the  muscles  to  faradic  irri- 
tability. 

"4.  The  complete  disappearance  of  the  symptoms  under  deep 
chloroform  necrosis. 

"  There  were  also  the  peculiar  hysterical  posture  of  the  patient 
and  the  difference  between  the  symptoms  in  the  two  limbs." 

Still  another  case  of  hemiplegia  is  reported  in  the  Johns  Hop- 
kins Hospital  Bulletin  for  July,  1896,  by  Haynes,  as  having  pre- 
sented itself  at  the  Brooklyn  Eye  and  Ear  Hospital.  A  man  of 
thirty  years  suffered  in  October,  1895,  from  an  attack  of  typhoid 
fever  lasting  twenty-one  days.  On  the  fourteenth  day  his  left  arm 
became  paralyzed,  and  when  able  to  sit  up  it  was  found  that  both 
upper  and  lower  extremities  felt  numb,  although  there  was  no  loss 
of  sensation.  This  condition  persisted  for  a  couple  of  months, 
when  improvement  began,  first  in  the  leg ;  almost  complete  re- 
covery ensued  so  that  only  slight  loss  of  motion  and  inability 
existed.  There  was  no  evidence  of  facial  paralysis  or  convulsions 
in  this  case. 

As  an  indication  of  the  possible  effects  of  embolism  of  the  cra- 
nial vessels,  the  case  recorded  by  Mensel  may  be  cited,  in  which 
necrosis  of  the  skull  followed  the  formation  of  a  clot  in  the  middle 
meningeal  artery. 

Aphasia  or  other  disturbances  of  speech  after  enteric  fever  have 
also  been  recorded  by  a  number  of  observers  without  simultaneous 
hemiplegia.  Thus  Hutinel1  tells  us  that  aphasia  always  occurs  in 
children,  and  more  frequently  in  boys  than  in  girls.  In  some  of 
these  instances  the  condition  arises  from  embolism,  but  in  other 
cases  recovery  has  ensued  so  rapidly  that  no  severe  organic  cause 
of  this  character  could  have  been  present,  and  this  has  been  proved 
by  the  failure  to  find  embolism  at  autopsy.  Leyden  has  expressed 
the  view  that  such  cases  may  be  due  to  a  mild  degree  of  encepha- 
litis with  readily  absorbed  exudation. 

Mental  disturbance  following  typhoid  fever  is  by  no  means  rare, 
and  varies  in  degree  from  slight  mental  enfeeblement  and  inability 

1  Etude  sur  la  Convalescence  et  les  Eechute  de  la  Fievre  Typhoi'de,  Paris,  1S83. 


COMPLICATIONS  DURING  CONVALESCENCE.  235 

to  do  mental  work  to  marked  insanity.  When  the  patient  is  vio- 
lent they  are  said  by  some  persons  to  have  "  asthenic  mania."  It 
is  not  mania,  but  the  insanity  of  profound  mental  and  physical 
depression.  These  variations  from  the  normal  are  usually  fol- 
lowed by  recovery,  as  is  pointed  out  in  the  interesting-  chapter 
on  the  mental  disorders  of  the  late  stage  of  typhoid  fever,  which 
has  been  contributed  to  this  essay  by  the  author's  friend  and  col- 
league, Dr.  F.  X.  Dercum,  Clinical  Professor  of  Diseases  of  the 
Nervous  System  in  the  Jefferson  Medical  College. 

Rathery1  and  Hutinel  have  recorded  cases  of  post-typhoid 
tremor.  In  one  of  Rathery's  cases  it  persisted  fifteen  months  after 
the  fever  ceased.     Similar  cases  have  been  recorded  by  Freund.2 

Fry,3  of  St.  Louis,  records  a  case  of  so-called  paralysis  agitans 
following  immediately  after  typhoid  fever.  The  trouble  began  with 
the  ending  of  the  fever  in  a  tremor,  which  gradually  increased  in 
violence,  and  chiefly  involved  the  right  arm  and  later  the  left. 
Still  later  the  legs  were  involved.  No  definite  reason  for  believ- 
ing the  case  to  be  Parkinson's  disease  and  not  one  of  ordinary 
tremor  is  vouchsafed. 

Gubler4  has  recorded  amaurosis  and  strabismus  after  typhoid 
fever,  and  the  latter  symptom  has  also  been  seen  by  Nothnagel.5 
Paralysis  of  the  soft  palate  has  also  been  recorded  by  Gubler,  and 
of  the  vocal  cords  by  Turck  and  Nothnagel.  All  these  symptoms 
are  but  evidences  of  the  peripheral  neurites  already  discussed. 

Bouley  and  Mendel6  state  that  paralysis  of  the  vocal  cords  fol- 
lowing typhoid  fever  is,  in  their  opinion,  an  exceedingly  rare 
condition.  They  claim  they  have  only  found  ten  other  cases  in 
literature  which  are  carefully  described  and  three  others  briefly 
mentioned.  In  some  of  these  cases  there  was  complete  paralysis 
of  the  recurrent  laryngeal  nerve  with  profound  paralysis  of  the 
adductors.     Bernoud"  has  also  reported  cases. 

1  Des  Accidents  de  la  Convalescence,  Paris,  1875. 

2  Inaugural  Dissertation,  Breslau,  1885. 

3  Journal  of  Nervous  and  Mental  Diseases,  1897,  p.  465.  4  Loc.  cit. 
5  Loc.  cit.  6  Archives  Gonerale  de  Medecine,  December,  1S94. 
7  Lyon  Medicale,  March  28,  1897,  p.  453. 


236     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

Paralysis  of  the  laryngeal  muscles  is  probably  more  common 
than  is  generally  thought,  arising,  as  a  rule,  from  neuritis.  Thus 
Przedlorski  found  in  100  consecutive  cases  no  less  than  25  cases 
with  paralysis. 

Very  recently,  at  a  meeting  of  the  Laryngological  Section  of 
the  College  of  Physicians  of  Philadelphia,  Dr.  MacCoy  reported 
three  cases  of  this  rather  rare  condition  of  laryngeal  paralysis 
complicating  typhoid  fever.  As  he  well  said  in  his  preliminary 
remarks  : 

"  We  can  most  simply  classify  these  paralyses  under  the  various 
functions  performed  by  the  larynx.  Keeping  clearly  in  mind  that 
the  chief  function  of  sets  of  laryngeal  muscles  is  to  open  and  close 
the  glottis,  we  can  simplify  the  clinical  facts  by  grouping  them 
under  the  two  heads  of  paralysis  of  adduction  and  of  abduction. 
Paralysis  of  adduction  in  its  various  forms  is  of  very  great  interest, 
and  enters  largely  into  our  most  interesting  laryngological  experi- 
ences ;  but  it  concerns  phonation  only — a  most  wonderful  function, 
but  not  necessary  to  life.  Abduction,  on  the  other  hand,  concerns 
the  very  existence  of  life — respiration.  A  moment's  faltering  in 
the  function  of  the  openers  of  the  larynx,  and  we  cease  to  exist. 
Being,  then,  of  so  vital  importance,  we  must  promptly  recognize, 
during  the  course  of  a  prolonged  and  wasting  acute  disease  like 
typhoid  fever,  the  imminent  risk  to  life  when  the  abductor  muscles 
are  paralyzed." 

Dr.  MacCoy  has  been  good  enough  to  send  me  the  following 
reports  of  his  cases  for  mention  in  these  pages : 

The  first  case  he  saw  was  one  of  posterior  crico-arytenoid  paral- 
ysis. It  was  double  or  bilateral,  and  occurred  in  a  case  of  typhoid 
fever  at  a  suburban  hospital.  The  subject  was  a  young  man  who 
had  had  a  severe,  prolonged  and  complicated  attack.  The  patient 
had  been  ill  for  over  two  months,  was  greatly  emaciated,  and  pro- 
foundly debilitated.  One  night  he  was  suddenly  seized  with  a  suf- 
focative attack  simulating  croup.  Getting  no  relief  whatever  from 
remedies  applied,  Dr.  MacCoy  was  asked  to  see  the  case.  The 
patient  was  greatly  distressed  in  his  respiration  and  cyanosed. 
Inspiration   was    performed   laboriously,   each    inspiration    being 


COMPLICATIONS  DURING  CONVALESCENCE.  237 

accompanied  by  stridor,  and  the  patient  appeared  almost  mori- 
bund. Larvngoscopic  examination  showed  a  complete  double 
paralysis  of  the  openers,  the  vocal  bands  remaining  fixed  in  the 
median  line.  Accompanying  paralysis  of  the  arytenoid  muscles 
with  loss  of  tension  enabled  the  patient  to  get  a  little  air  through  a 
small  triangular  slit  at  the  most  posterior  portion  of  the  glottis. 
As  promptly  as  possible  an  adult  intubation  tube  was  inserted  into 
the  larynx.  This  was  accomplished  without  much  distress  or 
trepidation  to  the  patient.  The  effect  of  the  intubation  was  magi- 
cal ;  complete  relief  to  breathing  instantly  followed,  and  in  a  few 
minutes  the  patient  was  in  a  quiet  sleep. 

The  second  subject  presented  himself  for  consultation.  He  was 
a  young  man  of  twenty-three  years.  He  wore  a  tracheotomy  tube. 
The  history  showed  that  he  had  had  a  severe  attack  of  typhoid 
fever  in  the  South  a  few  months  previously.  During  convales- 
cence he  was  seized  with  a  grave  suffocative  attack,  and  was  in 
such  a  serious  condition  as  to  require  tracheotomy,  which  relieved 
him  completely.  Examination  of  the  larynx  showed  a  complete 
fixation  of  the  vocal  bands  in  the  median  line.  This  patient 
could  not  do  without  the  tube,  and  he  requires  it  to  the  present 
time.  He  has  a  most  clever  device  of  a  valve  and  rubber 
tubing  and  rubber  bulb  connected  with  the  canula,  by  which 
air  is  made  to  close  the  valve  against  the  mouth  of  the  canula, 
and  so  he  is  enabled  to  carry  on  conversation  with  ease  and 
fluency.  In  this  case  intubation  was  attempted  but  failed  of  intro- 
duction. The  subject  enjoys  good  health  and  is  active  in  business 
pursuits. 

The  third  case  was  a  soldier  in  one  of  the  city  hospitals,  who 
was  suffering  from  great  dyspnoea.  Larvngoscopic  examination 
showed  complete  apposition  of  the  vocal  bands  in  the  median  line 
with  enough  relaxation  of  tension  and  arytenoidal  paralysis  to 
allow  a  little  air  to  enter.  Intubation  was  strongly  urged,  but  the 
visiting  physician  was  relucant,  and  the  subject  died  of  exhaustion 
in  a  short  time.  In  MacCoy's  judgment,  prompt  intubation  in 
this  case  would  have  saved  the  man's  life. 

Finally,  cases  of  chorea  have  been  recorded  by  Rilliet   and 


238     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

Barthez,  but  these  may  have  been  cases  of  tremor  rather  than 
chorea. 

Sometimes  in  the  convalescence  a  curious  state  is  developed  in 
which  the  muscles  of  the  lower  extremities  become  painful,  some- 
what brawny,  and  even  slight  redness  may  appear  in  the  skin 
covering  them.  Usually  this  is  unilateral,  but  it  may  be  bilateral. 
Most  commonly  it  affects  the  calf  of  the  leg,  and  pain  is  developed 
on  pressure  or  on  movement,  active  or  passive.  Osier  believes 
this  to  be  a  myositis.  Whatever  it  may  be,  the  author  can  indorse 
the  statement  that  the  condition  is  painful,  from  his  own  experi- 
ence, although  the  condition  was  not  well  developed. 

Many  years  ago  V.  P.  Gibney,  of  New  York,  described  under 
the  name  of  "typhoid  spine,"  a  condition  in  which  there 
develops,  often  some  days  after  the  patient  is  up  and  about,  and 
often  only  after  some  very  slight  jar  or  trauma,  great  tenderness 
of  the  spine,  and  pain  in  the  back  and  in  the  legs  when  they  are 
moved.  This  condition  is  not  dependent  upon  a  spondylitis, 
neuritis,  or  Pott's  disease,  and  is  probably  a  neurosis  closely  allied 
to  the  neuroses  seen  in  severe  cases  of  trauma. 

Sometimes  neurotic  patients,  particularly  women,  suffer  from 
hysterical  attacks  of  causeless  weeping  while  convalescence  pro- 
gresses, and  in  a  case  under  the  writer's  care,  during  convalescence, 
a  strong  and  hearty  man,  a  member  of  the  city  fire  department, 
cried  like  a  child  whenever  one  of  his  fellows  came  to  visit  him. 

Severe  hysteria  sometimes  complicates  convalescence  in  typhoid 
fever.  Thus  Simpson1  records  the  case  of  a  woman  who  was  sud- 
denly seized  with  unconsciousness  and  rigidity  during  convalescence  ; 
she  was  confined  to  bed  for  nine  years,  but  had  regular  attacks  on 
each  succeeding  Sunday,  the  day  on  which  the  first  attack  occurred. 
Constant  vomiting  was  also  present. 

A  condition  of  very  great  rarity  after  enteric  fever  is  tetany. 
Janeway  has  reported  cases  coming  on  during  the  height  of  typhoid 
fever,  the  tenth  and  twenty-fourth  days. 

Pseudo-hypertrophic  muscular  changes  have  been  recorded  as 

1  Edinburgh  Medical  Journal,  January,  1896. 


COMPLICATIONS  DURING  CONVALESCENCE.  239 

occurring  after  typhoid  fever  by  Lasage.1  The  patient,  a  man  of 
twenty-seven  years,  was  seized  on  the  nineteenth  day  of  the  attack 
with  aeute  pain  in  the  left  thigh  and  with  other  symptoms,  which 
caused  a  diagnosis  to  be  made  of  phlegmasia.  Swelling  of  the 
limb  did  not,  however,  disappear,  and  several  months  later  it  was 
found  to  be  greatly  increased,  the  hypertrophy  involving  the  mus- 
cular masses,  which  were  larger  and  firmer  than  in  the  right  leg, 
although  the  electrical  reactions  were  not  impaired,  nor  were  the 
reflexes.  Exercising  the  muscles  on  this  side  produced  cramp-like 
contractions.  At  the  time  the  case  was  reported  the  condition  had 
persisted  for  two  years. 

The  following  references  for  which  I  am  indebted  to  Ross  and 
Bury's  monograph,  may  be  of  interest  in  this  connection  : 

Meyer.  Die  Elektricitat  auf  Praktische  Medicin,  Berlin,  1861, 
p.  311. 

Leudet.  "  Remarques  sur  les  Paralysies  Essentielles  Consecu- 
tives  a  la  Fievre  Typhoide,"  Gaz.  Med.  de  Paris,  1861. 

Imbert-Gourbeyre.  "  Recherches  Historiques  sur  les  Paralysies 
Consecutives  aux  Maladies  Aigues,"  Gaz.  Med.  de  Paris,  1861. 

Handfield-Jones.  "Abstract  of  a  Clinical  Lecture  on  a  Case  of 
Paralytic  Contracture  after  Fever,"  Medical  Times  and  Gazette, 
1867,  p.  390. 

Murchison.  A  Treatise  on  the  Continued  Fevers  of  Great  Brit- 
ain.    Second  edition,  1873,  p.  225. 

Teale  and  Morven,  quoted  by  JNotlmagel.  Deutsche  Archiv  f. 
Id  in.  med.,  1872. 

Rehn.  "  Ein  Fall  von  Lahmung  der  Glottiserweiterer  nach 
Typhus  Abdominalis,"  Deutsches  Arch.  f.  Min.  Med.,  Bd.  xviii.  p. 
136. 

Landouzv.  Des Paralysies  dans  les  Maladies  Aigues.  Paris,  1880. 

Baumler  (C).  "  Ueber  Lahmung  des  Musculus  Serratus  Antieus 
major  nach  Beobachtungen  an  Cinem  Fall  von  Multiplen  Atro- 
pischen  Lamungen  im  Gefolge  von  Typhus  Abdominalis,"  Deutsches 
Archiv.  /.  hlin.  Med.,  1880,  vol.  xxv.  p.  305-324. 

1  Revue  de  Medecin,  November  10,  1889. 


240     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

Stintzing  (R.).  "  Typhus  Abclominalis  mit  Nachfolgender  Atro- 
pischer  Lahmung,"  Aertztl.  Int.  Bl.,  Munchen,  1883,  vol.  xxx.  p.  4. 

Bartholow  (R.).  "  Enteric  Paraplegia,"  Medical  News,  Phila- 
delphia, 1883,  vol.  xliii.  p.  609. 

Rondot  (E.).  "  Contribution  a  1' Etude  des  Paralysies  qui  Sur- 
viennent  dans  la  Fievre  Typhoide ;  Paraplegie  et  Amyotrophie 
Myelopathiques  d'Origine  Typhoi'dique,"  Gaz.  Hebd.  de  Sci.  Med. 
de  Bordeaux,  1885,  vol.  vi.  p.  446. 

Peliotis.  Be  la  Nivrite  Pe'ripherique  du  Cubital  Consecutif  a 
la  FiSvre  Typhdide.     Paris,  1885,  Th6se. 

Raymond.  "  Deux  Cas  de  My  elite  Ascenclante  Observes  pendant 
la  Convalescence  de  la  Dothienenterie,"  Revue  de  Medicine,  1885, 
p.  648. 

Courtade  (D.).  "Des  Paraplegies  Survenant  dans  le  Cours  ou 
pendant  la  Convalescence  de  la  Fievre  Typhoide,"  U Encephale, 
Paris,  1886,  vol.  vi.  p.  431. 

Wiirtz.  "  Note  sur  un  Cas  de  Nevrite  Tibial  Anterieur  Survenue 
dans  le  Cours  d'une  Fievre  Typhoide,"  I? Encephale,  1886. 

Buzzard  (T.).    Paralysis  from  Puerperal  Neuritis,  1886,  p.  102. 

Bassi  (U.).  "  Nevrite  Multipla  Consecutiva  a  Febbre  Tifoide," 
B6v.Veneta  di  Sc.  Med.,  Yenezia,  1887,  vol.  vi.  p.  585. 

Oppenhehn  and  Siemerling.  "  Beitrage  zur  Pathologie  der 
Tabes  Dorsalis  und  der  Peripherischen  Nervenerkrankung," 
Archiv  fur  Psychiatrie,  1887,  p.  509. 

Puybaret  (J.  A.  C).  Contribution  a  V Etude  des  Paralysies  dans 
la  Fievre  Typhdide,  Bordeaux,  1887,  Thesis. 

Stadehnann.  "  Ueber  einen  Eigenthiinilichen  Mikroskopischen 
Befund  in  den  Plexus  Brachialis  bei  einer  Neuritis  in  Folge  von 
Typhus  Abdominalis,"  Neurol.  Centralb.,  1887,  p.  285. 

Gowers.  A  Manual  of  Diseases  of  the  Nervous  System,  vol.  ii. 
p.  824. 

Stoney  (W.).  "  Paralysis  of  Extensor  Muscles  of  Thigh  Fol- 
lowing Enteric  Fever,"  Medical  Press  and  Circular,  1889,  N.  S., 
vol.  xlvii.  p.  562. 

Kebler  (J.).  "Post-typhoid  Paralyses,"  Cincinnati  Lancet- 
Clinic,  1889,  N.  S.,  vol.  xxiii.  p.  35. 


COMPLICATIONS  DURING  CONVALESCENCE.  241 

Longstreth  (M.).  "  Neuritis  after  Typhoid  ;  Rheumatic  Neu- 
ritis," Physician  and  Surgeon,  Ann  Arbor,  Mich.,  1887,  vol.  i.\. 
p.  201. 

Comte.  "  Un  Cas  de  Paralysie  Generalised  a  la  Suite  de  la 
Fievre  Typhoi'de,"  Poiteau  Mfrl.,  Poitiers,  1887,  Tome  ii.  p.  113. 

Schmidt  (F.).  "  Ueber  Neuritsche  Lahmungen  nach  Abdomi- 
naltyphus,"  Niirnberg,  1891. 

Pal.     "Uber  Multiple  Neuritis,"  Wien,  1891,  p.  37. 

The  Skin  in  the  Stage  of  Convalescence.  Aside  from  boils, 
carbuncles,  and  gangrene,  which  may  appear  at  this  time,  and 
which  have  been  discussed  under  the  heading  of  the  well-devel- 
oped stage  of  the  malady,  we  find  as  the  most  common  compli- 
cation at  this  time  erysipelas.1 

According  to  Liebermeister,  this  complication  occurs  generally 
during  convalescence  and  seldom  at  the  height  of  the  disease,  and 
he  believes  it  may  be  a  dangerous  factor.  In  1420  cases  of  typhoid 
fever  in  Basel,  erysipelas  appeared  ten  times,  and  all  of  the  ten 
recovered.  These  were  all  cases  of  facial  erysipelas.  Two  others 
developed  the  disease  about  bed-sores.  In  other  words,  erysipelas 
occurred  in  a  little  less  than  1  per  cent,  of  these  cases.  Griesin- 
ger2  states  that  it  occurs  in  about  2  per  cent.  Taupin  (1839) 
speaks  of  two  cases  of  erysipelas  of  the  face  occurring  in  children 
suffering  from  typhoid  fever. 

The  following  cases  occurred  within  a  period  of  six  weeks  of 
each  other  in  the  wards  of  St.  Agnes' s  Hospital  under  my  care. 
The  first  case  was  separated  from  the  second  by  an  interval  of  five 
weeks,  and  the  second  from  the  third  by  less  than  a  week.  They 
were  all  in  the  same  ward,  but  occupied  beds  at  least  twenty  feet 
apart.     The  first  case  is  as  follows  : 

Maggie  T.,  aged  twenty-two  years,  was  admitted  December  16, 
1890,  with  a  history  of  chronic  suppuration  of  the  middle  ear. 
She  was  treated  at  the  dispensary,  and  rapidly  improved,  being 
discharged  on  December  23d.     On  January  8,  1891,  she  was  re- 

1  See  article  by  Hare  and  Patek  in  the  Medical  News,  January,  1891. 

2  Infectionskrunkheiten. 

16 


242     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

admitted  with  well-defined  symptoms  of  a  mild  attack  of  typhoid 
fever;  which  ran  a  short  course,  the  patient  being  discharged  on 
January  30th.  On  February  2d  she  entered  the  house,  complain- 
ing of  pain  in  the  abdominal  region  and  in  the  knees  and  elbows ; 
the  pains  were  not  very  severe,  but  the  joints  were  somewhat 
swollen ;  the  tongue  was  brown  and  dry,  and  all  the  symptoms, 
such  as  the  stools,  the  rose-colored  spots,  the  characteristic  tempera- 
ture and  appearance  of  the  patient,  pointed  to  a  second  attack  of 
typhoid  fever,  although  at  first  the  case  was  treated  as  one  of 
rheumatism.  The  temperature  did  not  exceed  103°,  and  the 
patient  went  through  a  moderately  severe  attack  of  typhoid  fever 
without  complication,  except  for  very  marked  enlargement  of  the 
glands  of  the  neck,  which  was  relieved  very  promptly  by  the  use 
of  an  ice-collar.  On  March  5th  a  well-defined  erysipelatous 
swelling  appeared  over  the  left  side  of  the  face,  about  the  temples 
and  malar  bones,  and  gradually  extended  over  the  entire  face  and 
part  of  the  scalp.  The  eyes  were  completely  closed,  and  the  lips 
very  much  swollen.  The  mouth  was  very  painful,  being  covered 
with  sores  to  such  an  extent  that  it  was  impossible  for  the  tongue 
to  be  protruded,  and  it  was  impossible  for  food  to  be  taken.  The 
throat  was  very  dry,  and  a  spray  of  listerine  was  used  as  mouth- 
wash. The  ordinary  treatment  for  typhoid  fever  was  at  once  with- 
drawn, and  the  patient  was  put  on  thirty  drops  of  the  tincture  of 
chloride  of  iron,  three  times  a  day.  Under  this  treatment  she 
improved,  and  by  March  16th  all  inflammation  had  entirely  dis- 
appeared, leaving  only  some  swelling,  which  in  the  course  of  the 
next  two  weeks  entirely  passed  away.  The  patient  during  this 
time  continued  to  manifest  symptoms  of  typhoid  fever,  and  was 
unable  to  leave  her  bed  on  account  of  this  disease  for  three  weeks 
after  the  erysipelas  had  disappeared.  Total  recovery  eventually 
took  place. 

The  second  case  was  that  of  A.  E.,  a  female  aged  twenty  years, 
who  was  admitted  to  my  wards  with  all  the  early  symptoms  of 
enteric  fever,  which  developed  into  a  moderately  severe  attack, 
but  was  without  any  extraordinarily  severe  symptoms.  It  was 
estimated  that  at  the  time  the  erysipelas  developed  she  was  in  the 


COMPLICATIONS  DURING  CONVALESCENCE.  243 

third  week  of  the  typhoid  fever.  At  the  onset  of  the  erysipelas 
there  was  a  chill,  followed  by  a  rise  of  temperature  of  2°,  and 
followed,  after  the  use  of  a  cold  bath,  by  a  fall  to  the  temperature- 
course  previously  pursued.  The  erysipelas  began  about  the  bridge 
of  the  nose  and  extended  rapidly  over  the  entire  face  back  to  the 
ears  and  to  the  margin  of  the  hair,  whence  it  ceased  to  spread. 
The  eyes  were  closed  and  the  lips  much  swollen.  An  examination 
of  the  serum  withdrawn  by  a  lancet  showed  the  characteristic 
streptococci  of  erysipelas.  Under  the  use  of  large  doses  of  tinc- 
ture of  the  chloride  of  iron  and  an  application  of  ichthyol  oint- 
ment, recovery  rapidly  took  place.  The  mouth  was  unusually  foul 
and  dry,  but  no  delirium  was  present.  We  could  not  notice  that 
the  complication  in  any  way  increased  the  gravity  of  the  case. 

The  third  case  is  as  follows  :  A  woman,  aged  nineteen  years,  a 
Swede,  was  admitted  in  the  early  stages  of  typhoid,  which  ran  a 
mild  course,  devoid  of  delirium  or  any  symptoms  of  importance, 
except  that  on  an  afternoon,  about  the  middle  of  the  third  week 
of  her  illness,  she  developed  a  sudden  rise  of  temperature  to  104°, 
followed  at  once,  on  the  use  of  cold  bathing,  by  a  fall  to  98°,  with 
loss  of  the  pulse  at  both  wrists.  As  a  precautionary  measure,  she 
was  treated  as  if  suffering  from  intestinal  hemorrhage,  and  soon 
rallied,  developing  during  the  next  twelve  hours  a  typical  patch 
of  erysipelas  on  the  right  side  of  the  nose  and  over  the  malar 
bone.  There  was  no  further  disturbance  of  the  typhoid  tempera- 
ture, and  the  disease  remained  limited  to  that  side  of  the  face. 
The  patient  was  treated  with  iron  and  ichthyol. 

By  far  the  most  exhaustive  study  which  we  have  found  con- 
cerning erysipelas  as  a  complication  of  typhoid  fever  is  that  of 
Gerente.1  According  to  this  authority,  the  complication  comes  on 
in  one  of  every  sixty-one  cases,  which  would  give  a  much  higher 
percentage  than  that  of  Liebermeister  or  Griesinger.  Gerente 
states  that  females  are  more  commonly  affected  than  males,  which 
is  a  curious  fact,  because  males  are  more  exposed  and  more  fre- 
quently have  typhoid  fever.     In  regard  to  the  period  of  the  disease 

1  These  de  l'Ecole  de  Me'decine.  18S3-84,  t.  i. 


244     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 


at  which  erysipelas,  as  a  rule,  appears,  Gerente  states  that  it  is 
generally  after  the  twenty-first  day,  and  he  also  believes  that 
some  epidemics  of  typhoid  are  peculiarly  liable  to  this  complica- 
tion. The  following  conclusions  of  Gerente,  however,  embody 
most  of  his  statements  : 

Eysipelas  of  the  face  is  rarely  met  with  during  the  course  of 
typhoid  fever.  I  have  found  it  in  64  out  of  3910  cases,  which  is 
about  1  to  61.  These  figures  are  derived  from  the  following 
statistics  : 


Typhoid  fever    Erysipelas, 
eases.  cases. 


Choniel   . 
Louis 
Forget     . 
Jenner     . 
De  Larroque 
Zuelzer    . 
Liebermeister 
Zuccarini 
Griesinger 
Murchison1 


Total 


130 

4 

134 

3 

92 

1 

65 

2 

105 

4 

84 

3 

1420 

10 

480 

18 

500 

10 

900 

9 

3910 


64 


agion,  it  appears  to  be  most  fre- 
ms  of  typhoid,  and  in  those  of 


Outside  of  the  question  of  conte 
quent  in  the  grave,  adynamic  fori 
long  duration  ;  it  appears  to  be  most  frequent  in  lymphatic  subjects. 

While  observed  at  all  the  stages  of  typhoid  fever,  erysipelas 
shows  itself  especially  and  almost  exclusively  during  the  last 
period  and  during  convalescence. 

Under  these  circumstances  erysipelas  produces  a  marked  ameli- 
oration in  the  general  as  well  as  in  the  local  symptoms. 

The  appearance  of  facial  erysipelas  in  the  course  of  typhoid 
fever  is  of  grave  prognosis  (sixteen  deaths  out  of  thirty-six  cases) ; 
this  gravity  lies  less  in  the  erysipelas,  which  most  frequently  is 
benign  in  itself,  than  in  the  poor  general  condition  of  the  patient, 
the  secondary  infection  being  an  indication  of  this  condition. 

The  complication  consists  in  a  simple  coincidence  favored  by 
debility,  the  result  of  the  primary  and  principal  disease. 


1  The  number  of  Murchison's  cases  is  not  strictly  correct. 


COMPLICATIONS  DURING  CONVALESCENCE.  245 

We  think  the  statement  that  erysipelas  seriously  influences  the 
prognosis  in  all  cases  too  swooping.  Thus,  there  are  cases  on 
record  in  which  the  onset  of  the  acute  disease  has  not  in  any  way 
retarded  convalescence.  If  the  disease  becomes  phlegmonous  the 
prognosis  is,  of  course,  very  grave ;  but  if  the  inflammation  is 
capable  of  undergoing  resolution  the  prognosis  is  good. 

The  question  as  to  the  path  by  which  contagion  finds  entrance 
has  been  much  discussed,  but  the  opinion  of  Griesinger  is  gener- 
ally accepted.  He  believes  that  the  germs  gain  entrance  by  means 
of  the  inflammation  of  the  frontal  or  sphenoidal  sinuses,  and  also 
when  ulceration  of  the  buccal  mucous  membrane  exists.  Zeulzer 
also  points  out  that  in  his  owrn  cases  and  in  those  of  Zuccarini  the 
erysipelas  started  in  the  stomatitic  spots  and  ulcerations  in  the 
mouth. 

In  all  our  cases  the  patients  complained  very  much,  both  before 
and  after  the  attack  of  erysipelas,  of  the  soreness  of  their  mouths. 
The  following  cases  which  have  been  reported  in  addition  to  the 
three  of  Gerente  are  interesting  : 

Armieux1  reports  the  case  of  a  soldier  in  whom  typhoid  symp- 
toms set  in  on  September  18, 1881,  with  pain  in  the  head,  vertigo, 
abdominal  tenderness,  pain  in  the  right  iliac  fossa,  and  an  elevated 
temperature.  On  October  4th  a  complication  arose  in  an  otorrhoea 
which,  by  the  2 2d,  was  growing  steadily  worse,  so  that  the  patient's 
condition  was  critical.  Now  facial  erysipelas  made  its  appearance, 
beginning  in  the  auditory  canal.  Early  in  November  osteitis  of 
the  humerus  set  in,  and  the  patient  died  on  November  9th. 

Thielman2  reports  the  case  of  a  man,  aged  thirty  years,  brought 
into  the  hospital  in  an  unconscious  condition.  The  right  ear,  eye- 
lids, nose,  greater  part  of  the  face  and  forehead  were  covered  with 
an  erysipelatous  eruption.  The  tongue  was  dry  and  brown  ;  there 
was  pain  in  the  ileo-csecal  region,  and  the  liver  was  painful  and 
enlarged.  The  fever  was  recognized  as  typhoid,  and  the  patient 
put  upon  calomel.     The  patient  was  in  a  delirious  condition,  but 

1  Rev.  Me"d.  de  Toulouse,  1875,  ix.  42. 

2  Med.  Jahresbuch  v.  Peter-Paul   Hospital  in  St.   Petersburg  (1840,   1841), 
142,  147. 


246     COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER. 

on  the  following  clay  there  was  a  slight  remission,  and  he  became 
partly  conscious.  The  erysipelas  was  seen  to  be  spreading  further 
over  the  face,  but  leaving  its  original  seat.  There  was  delirium 
the  following  night  and  semi-consciousness.  Desquamation  set  in 
on  the  right  side  of  the  face,  the  eruption  extending  on  the  left. 
The  pulse  grew  stronger,  but  the  tongue  was  still  brown  in  the 
centre.  The  patient  was  noticed  to  be  troubled  with  occasional 
cough,  and  the  respirations  were  somewhat  more  frequent.  Exam- 
ination showed  a  hypostatic  congestion  of  the  lungs.  The  condi- 
tion became  critical,  but  was  relieved,  and  the  patient  gradually 
improved,  being  dismissed  as  cured  on  the  thirty-fifth  day  after 
admission. 

M.  Berthoud1  reports  the  case  of  a  soldier  who  had  typhoid 
fever  of  a  meningeal  type.  The  typhoid  fever  was  declining,  but 
convalescence  was  tardy,  and  his  general  condition  was  unsatisfac- 
tory. At  this  time  the  scrotum  became  tumefied  and  red,  the  red- 
ness spreading  to  the  inguinal  regions,  while  the  general  condition 
became  very  poor.  The  scrotum  was  triple  its  natural  size,  red, 
moderately  warni,  tender,  not  very  painful,  but  cedematous,  the 
redness  extending  to  the  right  and  left  inguinal  regions  as  far  as 
the  anterior  superior  spinous  process,  and  also  to  the  internal 
aspect  of  the  thigh.  The  skin  in  these  parts  was  swollen  but  soft, 
and  the  color  persisted  on  pressure.  On  the  next  day  there  was 
no  amelioration  of  the  symptoms,  but  a  very  small  area  of  necrosis 
appeared  on  the  scrotum,  which  was  treated  by  the  application  of 
the  cautery.  On  the  following  day  the  necrosis  seemed  to  be 
arrested  and  the  scrotum  reduced  in  size.  The  general  condition, 
however,  remained  alarming.  Six  days  later  the  patient  died,  after 
a  subdelirium  of  four  hours.  The  autopsy  showed  that  the  iliac 
and  renal  veins  were  involved  in  a  plastic  and  suppurative  inflam- 
mation, a  case  of  erysipelas  in  the  veins.  The  conclusion  reached 
is  that  the  redness  of  the  skin  and  infiltration  were  due  purely  to 
mechanical  causes,  viz.,  the  stagnation  of  the  blood. 

Freudenberger2  has  recorded  two  cases,  in  one  of  which  erysip- 

1  Gaz.  des  Hop.  de  Paris,  1848,  vol.  v.  p.  29. 

2  Aertzl.  Intelligenzblatt,  Miinchen.,  1880,  xxvii.  p.  37. 


COMPLICATIONS  DURING  CONVALESCENCE.  247 

elas  appeared  suddenly  on  both  ears  in  the  course  of  typhoid  fever, 
without  unfavorable  symptoms.  On  the  following  day  a  chill  and 
rapid  advance  of  the  disease  took  place.  The  typhoid  fever  was 
now  considered  as  declining,  but  the  prognosis  grave,  because  of 
the  erysipelas.  In  the  second  case  facial  erysipelas  suddenly 
appeared  during  convalescence  from  typhoid  fever,  although  the 
temperature  was  already  quite  low.  The  fever  became  high  again, 
but  was  easily  influenced  by  antipyretics.     The  pulse  was  140. 

Potain1  reports  a  case  of  erysipelas  coming  on  during  convales- 
cence from  typhoid  fever,  which  was  accompanied  by  a  severe  chill 
and  fever.  The  erysipelas  began  in  the  pharynx  and  palate,  and 
did  not  affect  the  tonsils.  On  the  next  day  the  inflammation 
appeared  at  the  corners  of  the  mouth  and  on  the  face. 

Finally,  Martinez2  reports  the  following  cases  :  A  girl,  twenty 
years  of  age,  belonging  to  the  lower  class,  of  lymphatic  tempera- 
ment, with  very  irregular  menstruation,  which  was  often  almost 
absent,  was  taken  ill  with  typhoid  fever.  The  symptoms  were 
obscure  at  the  onset  of  the  disease,  but  the  most  prominent  mani- 
festation was  an  erysipelatous  inflammation  of  foot  and  leg.  On 
the  fourth  day  the  erysipelas  was  marked ;  there  was  great  fever, 
cephalalgia,  and  other  typhoid  symptoms,  such  as  weakness,  gur- 
gling in  the  right  iliac  fossa,  dryness  and  tremblings  of  the  tongue, 
sordes  on  the  teeth,  great  stupor,  delirium,  and  a  frequent  and 
small  pulse.     Death  took  place  after  some  days. 

Whether  the  erysipelatous  trouble  had  anything  to  do  with  the 
causation  of  the  typhoid  symptoms  or  not,  Martinez  does  not  state, 
but  he  mentions  the  case  of  another  woman  in  whom  an  extensive 
erysipelatous  inflammation  of  the  face  and  scalp  produced  cerebral 
symptoms,  fever,  etc.,  but  they  were  not  so  pronounced  as  to  be 
confounded  with  those  caused  by  true  typhoid  fever,  as  in  the 
present  instance.     In  this  case  the  patient  recovered. 

It  is  an  interesting;  fact  in  this  connection  that  Silvestrini3  has 


1  Erysipele  de  la  Face  Consecutif  a  la  Fievre  Tvphoi'de.     Gaz.  des  Hup.  de 
Paris,  1880,  liii.  p.  1106. 

2  La  Espana  Medica,  Madrid,  March  1,  1860,  p.  135. 

3  La  Riforma  Medica,  1894,  196,  197. 


248     COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID  FEVER. 

met  with  two  cases  of  facial  erysipelas  in  typhoid  fever,  in  which 
the  inflammation  was  found  to  be  due  not  to  streptococci  but  solely 
to  the  bacillus  of  Eberth.  He  asserts  that  Klebs  and  Reiner  have 
met  with  similar  cases. 

Very  often  in  the  last  week  of  defervescence  and  in  convales- 
cence the  patient  suffers  from  colliquative  sweating  of  a  marked 
type.  It  has  seemed  to  the  writer  that  in  these  cases  the  flow  of 
sweat  was  an  effort  at  elimination. 

Taupin1  tells  us,  in  an  article  written  as  long  ago  as  1839,  that 
in  children  it  is  common  to  meet  during  convalescence  with  very 
abundant  sweating  of  the  upper  part  of  the  body,  while  the  lower 
parts  remained  dry,  and  that  children  convalescing  from  typhoid 
fever  might  be  attacked  by  an  eruptive  fever.  He  also  speaks  of 
cases  attacked  by  scarlet  fever,  smallpox,  and  measles,  due,  in  all 
probability,  to  the  lack  of  isolation  in  fever  wards  in  those  days. 

Amitrano2  has  recorded  a  case  of  typhoid  fever  which,  during 
convalescence,  developed  the  scarlatiuiform  rash  which  desqua- 
mated. Marked  meningeal  symptoms  developed  after  the  fever 
subsided,  and  after  desquamation  was  completed  a  second  eryth- 
ema of  the  skin  appeared,  which  was  also  followed  by  desquama- 
tion. This  case,  perhaps,  belongs  to  the  class  of  dermatitis 
exfoliativa.  (See  last  chapter  for  a  discussion  of  typhoid  fever 
complicated  by  eruptive  diseases.) 

Profuse  desquamation  of  the  skin  is  frequently  met  with  in 
patients  convalescing  from  typhoid  fever.  The  writer  has  seen 
this  again  and  again,  and  Comby3  speaks  of  it  as  a  state  met  with 
in  the  convalescent  period  in  children. 

Coulon4  has  recorded  a  case  of  typhoid  fever  in  a  child  of  ten 
and  a  half  years,  in  which  there  was  general  desquamation  of  the 
skin  during  convalescence ;  previous  to  that  there  had  been  no 
eruption  upon  the  skin.  On  the  other  hand,  it  is  noteworthy  that 
there  had  been  sore-throat,  albuminuria,  and  oedenia,  so  the  case 

1  Journal  des  Connaissance  Medico-Chirurgicale,  1839,  No.  7. 

2  La  Kiforma  Medica,  1896,  No.  146. 

3  Gazette  des  Hopitaux,  1896,  No.  39. 

4  La  Medicale  Enfantile,  January,  1895. 


COMPLICATIONS  DURING  CONVALESCENCE.  249 

may  have  been  one  of  scarlet  fever  complicating  typhoid,  and 
without  the  ordinary  rash. 

A  somewhat  unusual  lesion  of  the  skin,  resulting  from  typhoid 
fever,  is  the  development  of  linese  albicantes.  Cases  of  this  kind 
have  been  reported  by  Troisier,1  and  Manouvriez  and  Bouchard 
have  also  recorded  such  instances.  It  is  stated  that  they  occur 
most  frequently  in  children  and  young  adults.  Bucquoy  notes 
that  in  boys  these  whitish  lines  have  no  special  area  of  distribu- 
tion, but  in  girls  the  breasts  and  crests  of  the  ileum  are  the  places 
where  they  usually  appear.  Barie  has  reported  the  case  of  a  girl 
of  seventeen  years,  in  whom  these  lines  appeared  over  the  knuckle- 
joints  of  each  hand. 

A  somewhat  similar  condition,  due  to  localized  atrophy  of  the 
skin,  is  recorded  by  Bradshaw.2  In  his  case  a  girl  of  thirteen  years, 
who  suffered  from  typhoid  fever  followed  by  relapse,  and  again  by 
a  second  relapse,  finally  developed  during  convalescence  upon  the 
inner  surface  of  the  lower  third  of  the  thigh  a  number  of  hori- 
zontal markings,  some  of  which  partially  surrounded  the  limb  ; 
they  were  about  one-half  inch  in  width,  regular  in  contour,  and 
almost  exactly  alike  on  both  legs.  A  similar  condition  has  been 
described  by  Wilkes.3 

A  very  rare  condition  coming  on  during  convalescence  in 
typhoid  fever,  is  reported  by  Leudet/  namely,  the  condition  of 
painful  oedema  of  the  thorax.  Paiu  was  first  felt  in  the  neigh- 
borhood of  the  thyroid  gland,  then  in  the  shoulder-blade  ;  later  a 
circumscribed  oedema  of  the  left  side  of  the  thorax  developed, 
which  was  not  reddened,  but  was  painful  to  the  touch.  There 
was  no  fever  and  no  albuminuria.  The  condition  lasted  for  four 
days  in  its  fully  developed  stage,  but  had  disappeared  entirely  by 
the  twelfth  day. 

The  Thyroid  Gland.  The  thyroid  gland  may  undergo  suppu- 
ration as  a  result  of  typhoid  fever,  as  it  may  in  other  infectious 

1  Bulletin  et  Memoire  de  la  Sock'te  Medicate  des  Hopitaux,  1S89,  No.  12. 

2  Bristol  Medico-Chirurgical  Journal,  July,  1889. 

3  Guy's  Hospital  Reports,  1861. 

*  La  Normandie  Mi'dicale,  October  1,  1891. 


250     COMPLICATIONS  AND  SEQTJELJE  OF  TYPHOID  FEVER. 

processes.  Thus  Pinchaud1  has  recorded  such  a  complication  of 
convalescence,  and  Forgue,2  a  Major  in  the  French  Army,  has 
made  a  contribution  on  this  condition.  Other  observers  have 
recorded  a  similar  state  complicating  the  other  infectious  diseases, 
and  the  view  is  generally  held  that  the  gland  becomes  infected 
from  the  entrance  of  the  bacillus  into  the  blood,  by  which  it  is 
carried  to  the  thyroid  gland.  The  most  recent  paper  on  this  topic 
with  which  I  am  acquainted  is  that  of  Testevin,3  a  Major  in  the 
French  Army,  who  under  the  title  of  "  Thyroidite  Infectieuse 
Suppuree,"  discusses  the  literature  of  the  subject.  From  his 
paper  it  is  evident  that  of  all  the  infectious  diseases,  typhoid 
fever  is  the  one  which  most  commonly  causes  these  lesions  in  this 
gland,  and  further,  that  it  is  emphatically  a  consecutive  or  second- 
ary manifestation  chiefly  met  with  in  convalescence.  In  very  rare 
instances  the  thyroiditis  develops  with  the  onset,  as  set  forth  by 
Tavel4  and  Laveran.5 

Finally,  it  is  a  noteworthy  fact  that  Chantemesse6  has  found  the 
bacillus  of  Eberth  in  the  pus  of  the  thyroid  gland. 

A  case  of  suppuration  of  the  right  lobe  of  a  goitrous  thyroid 
gland  has  been  recorded  by  Spirig,7  in  a  woman,  twenty-two  years 
of  age.  This  complication  arose  after  five  weeks  of  typhoid  fever, 
when  the  disease  was  on  the  decline ;  both  the  bacillus  of  Eberth 
and  the  staphylococcus  were  found  in  the  pus. 

Joints.  Articular  lesions  complicating  convalescence  from 
typhoid  fever  may  be  due  to  direct  infection  with  the  specific 
bacillus,  which  is  rare,  or  to  infection  by  other  organisms.  This 
question  is  ably  considered  in  Dr.  Keen's  monograph,  already 
quoted,  and  does  not  need  to  be  discussed  at  this  point  for  this  reason. 

1  Des  Thyroidites  dans  la  Convalescence  de  la  Fievre  Typhoi'de,  Paris,  1881. 

2  Contribution  a  l'Etude  de  la  Thyroidite  Typique.  Arch,  de  Med.  et  de  Phar. 
Milit.,  1886,  1.  vii. 

3  Ibid.,  February,  1899,  p.  126. 

*  Ueber  die  Etiologie  der  Strumitis,  ein  Beitriige  zur  Lehre  von  den  Hemato- 
genen  Infectionen,  Bale,  1892. 

5  Bevue  de  Chirurgie,  Septembre,  1890,  No.  29. 

6  Art.  Fievre  Typhoide  in  Traite  de  Med.  de  Bouchard  et  Charcot,  1891,  768. 

7  Correspondenzblatt  fiir  Schweizer  Aerzte,  February  1,  1892. 


COMPLICATIONS  DURING  CONVALESCENCE.  251 

Robin  and  Leredde1  have,  however,  called  attention  to  the  inter- 
esting: fact  that  acute  articular  inflammation  is  sometimes  met  with 
in  typhoid  fever,  and  believe  it  to  be  rheumatic  in  some  cases. 
On  the  other  hand,  in  the  great  majority  of  instances  the  joint 
affection  is  not  due  to  acute  articular  rheumatism,  but  it  is  simply 
an  evidence  of  the  septic  process  associated  with  the  typhoid  fever. 
Great  care  should  be  exercised  by  the  physician  that  mere  articular 
inflammation  does  not  mislead  him  in  an  erroneous  diagnosis. 

As  is  well  known,  dislocations  have  been  recorded  in  consider- 
able number  as  having  occurred  during  the  progress  of  typhoid 
fever  and  in  acute  rheumatism.  In  the  first  of  these  diseases  the 
displacement  of  the  bone  has  occurred  in  the  earlier  days  of  con- 
valescence, when  the  patient  has  been  so  feeble  that  it  has  seemed 
as  if  the  accident  was  due  to  the  relaxation  of  the  coverings  of 
the  joint  and  its  associated  muscles,  with  the  result  that  the  bone 
has  easily  slipped  out  of  place,  and  in  nearly  all  these  cases  there 
has  been  no  evidence  whatever  of  any  local  difficulty  prior  to 
luxation.  On  the  other  hand,  in  acute  articular  rheumatism  where 
dislocation  has  taken  place  there  has  nearly  always  been  a  history 
of  arthritic  difficulty  prior  to  the  accident,  and  instead  of  the  dis- 
location producing  pain  of  a  moderate  degree,  as  it  has  done  in 
convalescence  from  typhoid  fever,  the  occurrence  of  the  displace- 
ment has  been  followed  by  great  relief  from  pain,  owing  to  the 
overcoming  of  the  vicious  attitude  which  has  been  maintained  by 
the  limb.  The  cases  of  scarlet  fever  in  which  this  accident  has 
occurred  have  belonged  rather  to  the  typhoid  class,  in  that  the 
dislocation  has  taken  place  without  much  pain,  and,  therefore, 
without  attracting  great  attention  to  its  presence.  As  long  ago  as 
1882  Rawden  reported  in  the  Liverpool  Medico- Chirurgical  Jour- 
nal, an  instance  of  dislocation  following  typhoid  fever,  in  which, 
having  excised  the  head  of  the  bone,  he  found  it  practically  nor- 
mal, even  the  cartilage  being  healthy,  excepting  for  a  little  absorp- 
tion at  its  periphery ;  while,  on  the  other  hand,  Adams,  in  a  case 
of  rheumatic  dislocation  of  the  hip,  found  the  capsular  ligament 

1  Archives  Gdnerales  de  Mc'decine,  September,  1894. 


252     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

ruptured  aucl  the  torn  margins  of  the  rent  closely  embracing  the 
neck  of  the  bone.  AVhile  it  is  true  that  unobtrusive  monarticular 
synovitis  with  effusion  may  take  place  in  convalescent  patients,  the 
literature  of  the  subject  does  not  reveal  the  fact  that  post-typhoidal 
dislocations  have  usually  been  due  to  this  condition,  and  Collier 
believes  that  degenerative  changes  similar  to  those  seen  in  muscu- 
lar fibres  result  in  softening  of  the  ligaments  and  of  their  attach- 
ment to  the  bones.  The  possibility-  of  recurrence  of  the  dislocation 
under  such  circumstances  is  great,  and  the  prognosis  as  to  the 
correct  use  of  the  limb  must  be  made  with  caution,  since  some 
cases  seem  to  become  entirely  well,  while  others  never  get  rid  of 
a  certain  amount  of  anchylosis  or  shortening. 

In  this  connection  it  may  be  a  matter  of  interest  to  note  that  the 
case  of  typhoid  fever  under  my  care  in  the  wards  of  the  Jefferson 
Medical  College  Hospital  in  the  early  part  of  1897,  to  which  refer- 
ence is  made  in  Keen's  essay,  page  97,  has  been  seen  by  me  in 
March,  1899.  She  is  able  to  walk  without  the  aid  of  a  crutch,  but 
the  knee  is  permanently  anchylosed.  It  will  be  remembered  that 
aspiration  of  this  knee-joint  obtained  fluid  which  was  perfectly 
sterile.  A  much  more  interesting  point  in  connection  with  the 
case,  from  a  prognostic  point  of  view  for  other  cases,  is  that  the 
anchylosis  in  marked  flexion,  which  Dr.  Keen  thought  would 
require  operative  treatment  later  on,  has  been  gradually  overcome, 
so  that  shortening  in  the  anchylosed  limb  is  very  slight. 


CHAPTER    V. 

THE  CONDITIONS  WHICH  APE  TYPHOID  FEVEE. 

These  conditions  are  quite  numerous.  The  following  is  a  list 
of  the  more  common  of  these  conditions  :  Malarial  fever,  ap- 
pendicitis, sepsis,  pneumonia  with  great  asthenia,  tuberculosis, 
particularly  of  the  abdominal  contents ;  ileo-colitis,  ulcerative  or 
septic  endocarditis,  and  cerebro-spinal  meningitis. 

With  the  important  question  of  the  diagnosis  from  malarial 
fever  I  have  already  dealt  in  the  chapter  on  the  Well-developed 
Stage  of  the  Disease.  The  important  facts  for  the  physician  to 
remember  are  that  the  infection  by  the  bacillus  of  Eberth  and  that 
by  the  parasite  of  malarial  fever  may  pursue  a  course  in  each  case 
almost  identical  with  the  other,  and  that  in  such  cases  a  differen- 
tial diagnosis  is  to  be  made  chiefly  by  means  of  the  Widal  test  on 
the  one  hand  and  a  search  for  the  malarial  organism  on  the  other. 
It  is  also  to  be  recalled  that  the  quinine  test  is  not  of  great  nega- 
tive value,  and  that  its  persistent  use  in  a  malarial  case  may  simply 
make  the  microscopic  diagnosis  impossible.  On  the  other  hand, 
the  use  of  quinine  for  several  days  when  without  result  should  not 
be  persisted  in,  since  the  case  under  these  circumstances  is  probably 
not  due  to  malaria.  Speaking  of  this  therapeutic  test,  Dock  well 
says  :  "In  a  case  resembling  typhoid  fever,  but  really  malarial, 
the  microscope  is  essential  to  good  practice.  Without  it,  quinine 
may  again  be  used  ;  but  if  the  temperature  does  not  fall  to  or  near 
normal,  with  relief  to  the  other  symptoms,  it  is  better  to  stop  qui- 
nine altogether.  Only  when  microscopical  evidence  of  malaria  is 
present  should  the  drug  be  pushed  after  the  third  day.  It  is 
necessary  to  add  that  while  symptoms  persist  the  patient  should 
be  treated  as  though  he  had  typhoid  fever.  So  erroneously  is  the 
so-called  therapeutic  test  conceived,  that  I  have  known  of  patients 


254     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

taking  quinine  in  doses  of  forty  grains  a  day  for  three  weeks,  in 
order  to  determine  the  presence  of  malaria,  each  fall  of  one  or  two 
degrees  of  temperature  being  looked  on  as  proof  of  a  specific 
effect.  I  am  well  aware  that  some  look  on  massive  doses  of  qui- 
nine as  useful  in  typhoid  fever,  but  considerable  observation  has 
convinced  me  of  the  ojoposite  view." 

"With  these  views,  particularly  those  of  the  last  sentence,  the 
writer  is  in  entire  accord.  The  facts  already  well  emphasized  in 
this  essay,  that  severe  chills,  rigors,  and  sweats  may  appear  in 
many  cases  of  typhoid  fever  entirely  devoid  of  any  touch  of  mala- 
ria, proves  that  all  these  signs  are  not  proof  of  malarial  infection. 
In  confirmation  of  these  views  we  find  the  interesting  report  of 
Ewing,1  made  after  his  able  studies  among  soldiers  of  the  Spanish- 
American  war  at  Montauk  Point,  in  which  he  says  : 

"The  reason  why  the  blood  was  examined  in  159  cases  of 
tvphoid  fever,  was  the  intermittent  character  of  the  fever,  which 
was  exhibited  in  patients  both  with  and  without  malarial  antece- 
dents. In  no  case  of  undoubted  and  established  typhoid  fever 
were  malarial  parasites  found  in  the  blood  in  connection  with  any 
of  these  sudden  rises  of  temperature,  but  only  at  the  onset  of  the 
disease  or  during  the  convalescence. 

"On  the  other  hand,  many  patients  whose  blood  contained 
numerous  parasites  were  seen  in  the  '  typhoid  state,'  but  there 
were  always  some  essential  symptoms  lacking  to  confirm  the  diag- 
nosis of  typhoid  fever,  while  the  subsequent  course  of  the  disease 
demonstrated  the  purely  malarial  character  of  the  fever. 

"These  patients  might  suffer  from  epistaxis,  hseniatemesis, 
bloody  stools,  tympanites,  a  few  rose  spots,  though  oftener  herpes, 
diarrhoea  and  delirium,  and  in  some  a  partial  "Widal  reaction  was 
obtained.  But  the  intestinal  symptoms  were  inconstant  or  refer- 
able to  dysentery  or  simple  diarrhoea,  from  which  many  of  the 
malarial  cases  suffered,  and  these  patients  never  showed  subsultus 
or  cracked  tongues,  and  they  did  not  die,  or,  if  they  did,  dysen- 
tery and  malaria  were  demonstrated  at  or  before  autopsy." 

1  New  York  Medical  Journal,  February  4,  1899. 


CONDITIONS  WHICH  APE  TYPHOID  FEVER.  255 

Again,  he  says  :  "  It  is  possible  that  some  of  these  patients 
suffered  from  both  active  malaria  and  typhoid  fever,  but  there 
were  no  positive  indications  that  the  latter  infection  was  present. 
In  the  cases  that  came  to  autopsy  there  was  never  any  doubt  of 
the  nature  of  the  disease.  It  was  either  typhoid  fever  or  malaria, 
but  never  both,  although  microscopical  evidence  of  dormant  mala- 
rial infection  was  found  in  at  least  two  cases  of  typhoid  fever. 

"  In  short,  in  spite  of  very  painstaking  efforts,  the  attempt  to 
find  a  case  of  typhoid  fever  and  active  malaria  progressing  simul- 
taneously was  unsuccessful. 

"  From  a  study  of  this  group  of  cases  it  is  concluded  : 

"  1.  That  typhoid  fever  is  to  a  large  extent  incompatible  with 
active  malarial  fever,  and  that  during  the  course  of  the  former 
the  latter  infection  is  usually  suppressed. 

"  2.  That  the  presence  of  old  malarial  infection  may  alter  the 
course  of  typhoid  fever  through  the  anseinia,  but  that  active  sporu- 
lation  of  the  malarial  parasite  very  rarely  occurs  during  the  course 
of  established  typhoid  fever. 

"  3.  On  the  other  hand,  since  malarial  paroxysms  often  reappear 
during  convalescence,  a  scanty  growth  of  the  parasite  must  often 
persist  during  the  course  of  typhoid  fever,  and  it  is  possible  that 
some  of  the  irregularities  of  temperature  observed  in  these  cases 
are  referable  to  this  partly  suppressed  growth. 

"  4.  That  the  anatomical  evidence  of  a  post-mortem  examina- 
tion is  much  needed  to  demonstrate  the  existence  of  typhoid  fever 
in  cases  showing  active  malarial  paroxysms." 

A  valuable  paper  upon  the  relations  of  typhoid  fever  to  mala- 
rial infection  was  published  some  years  ago  by  Gilman  Thomp- 
son,1 in  which  he  reached  results  identical  with  those  just  stated, 
namely,  that  the  fever  of  typhoid  is  apt  to  run  its  course,  and 
that  malarial  manifestations  then  succeeds  it. 

Sepsis  and  appendicitis  may  somewhat  closely  resemble  typhoid 
fever  if  the  latter  affection  is  insidious  and  there  is  pus  present 
which  produces  toxaemia.     Whatever  the  cause  of  the  sepsis  may 

1  American  Journal  of  the  Medical  Science,  August,  1894. 


256     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

be,  the  loss  of  flesh,  dry  tongue,  delirium,  low-grade  bronchitis, 
badly  nourished  skin,  and  diarrhoea  may  cause  the  patient  to  be 
most  typhoidal  in  appearance,  yet  in  all  such  cases  we  should  seek 
for  a  possible  purulent  focus.  The  absence  of  the  Widal  reac- 
tion and  the  presence  of  leucocytosis  should  rouse  our  suspicions 
greatly,  and  it  is  not  to  be  forgotten  that  the  presence  of  pus  deep 
in  the  pelvis  or  in  the  neighborhood  of  the  kidney  may  not  be 
readily  discovered,  and  only  the  development  of  fluctuation  or  the 
rupture  of  the  abscess  will  force  the  physician  to  reverse  his  diag- 
nosis of  typhoid  fever.  On  the  other  hand,  as  already  pointed 
out,  purulent  formations  may  occur  in  typhoid  fever. 

Similar  facts  make  us  suspect  and  search  for  signs  and  causes 
of  ulcerative  endocarditis  in  such  cases. 

The  fact  that  tuberculosis  may  simulate  typhoid  fever,  and  that 
cerebro-spinal  meningitis  may  likewise  do  so,  has  already  been  dis- 
cussed in  the  foregoing  pages,  but  it  is  not  out  of  place  to  point 
out  that  four  types  of  tuberculosis  are  particularly  apt  to  produce 
misleading  symptoms.  In  tubercular  meningitis  the  febrile  move- 
ment is  rarely  as  high  as  in  typhoid  fever  with  associated  meningeal 
symptoms  ;  the  abdomen  is  usually  scaphoid  instead  of  tympanitic, 
and  the  persistent  vomiting  of  the  former  disease  is  comparatively 
rarely  met  with  in  the  latter.  An  ocular  examination  may  reveal 
optic  neuritis  in  tubercular  meningitis,  or  paralysis  of  the  muscles 
of  the  eyeball,  causing  squint. 

So,  too,  in  acute  general  miliary  tuberculosis,  the  previous  his- 
tory of  the  patient  as  to  gradual  failure  of  health,  and  cough,  the 
moderate  fever,  and  the  rigors  and  sweats  point  to  the  presence  of 
tuberculosis  rather  than  enteric  fever.  Further,  there  will  be  in 
some  cases  marked  physical  signs  of  widespread  involvement  of 
the  lungs  in  tuberculosis  which  will  be  absent  hi  typhoid  fever. 
It  is  to  be  recalled,  however,  that  a  roseolous  rash  may  develop  in 
both  affections,  and  that  diarrhoea  and  a  dry,  brown  tongue  may 
mislead  the  careless  very  readily.  Even  intestinal  hemorrhage 
may  occur  in  miliary  tuberculosis.1 

1  Senator.     Charite  Annalen,  1892,  vol.  xvii.  p.  272. 


CONDITIONS  WHICH  APE  TYPHOID  FEVER.  257 

Tubercular  peritonitis  may  also  cause  typhoid  symptoms,  but  as 
the  disease  progresses  the  localization  of  the  abdominal  symptoms 
and,  finally,  the  development  of  tumor  masses  or  enlargement  of 
the  mesenteric  glands,  can  be  felt  on  deep  palpation,  or,  in  other 
cases,  the  development  of  ascites  makes  the  diagnosis  clear. 

Finally,  it  is  not  necessary  for  the  rather  rare  disease,  general 
miliary  tuberculosis,  to  be  present  to  make  the  diagnosis  obscure. 
Some  time  since  I  saw  in  consultation  a  man  of  thirty  years, 
who  had  had  for  four  weeks  persistent  fever,  some  cough,  diar- 
rhoea, mild  delirium,  gradual  loss  of  flesh,  and  a  heavily  coated 
tongue,  with  sordes.  To  the  attending  physician  who  had  made  a 
diagnosis  of  enteric  fever  at  the  start,  nothing  had  occurred  to 
make  him  change  his  views,  but  the  appearance  of  the  patient 
made  me  suspicious  of  tuberculosis,  and  a  careful  examination  of 
his  chest  revealed  well-advanced  tuberculosis  of  the  lungs,  the 
real  cause  of  his  illness. 

Girandau1  has  recorded  a  case  in  which  a  young  man  suffered 
from  enteric  fever,  and  then  speedily  developed  tuberculous  disease 
of  the  intestines.  Two  weeks  after  the  recovery  from  enteric  fever, 
the  patient  became  ill  a  second  time  with  diarrhoea,  fever,  and 
abdominal  pain,  and  marked  wasting.  At  the  autopsy  two  sets  of 
lesions  were  found,  typhoid  lesions  side  by  side  with  tubercular 
foci.  jSTo  traces  of  old  pulmonary  lesions  or  a  primary  lesion  else- 
where were  to  be  found. 

An  interesting  case  illustrating  how  difficult  the  diagnosis  of 
typhoid  fever  may  be  in  its  earlier  stages  has  recently  been  under 
my  care : 

This  woman  was  taken  ill  some  days  before  I  saw  her  with 
chilliness,  fever,  and  languor,  and  with  a  further  history  that  she 
had  been  suffering  for  a  number  of  months  with  somewhat  similar 
sensations,  without  the  fever,  and  had  been  losing  flesh  ;  during 
this  time  she  had  had  constipation  alternating  with  diarrhoea  and 
abdominal  pain.  When  first  seen  her  temperature  Mas  103°,  her 
appearance  was  distinctly  that  of  a  typhoid  patient ;  but,  as  is  seen 

1  Revue  de  Medicine,  1884,  p.  564. 
17 


258     COMPLICATIONS  AND  SEQUEL JE  OF  TYPHOID  FEVER. 

in  the  accompanying  chart,  her  temperature  speedily  fell  to  nor- 
mal, only  one  sponge  bath  being  required  after  she  came  under 
observation.  An  examination  of  her  abdomen  at  this  time  re- 
vealed the  fact  that  it  was  slightly  protruding,  and  that  the  abdom- 
inal wall  was  so  thin  that  the  coils  of  intestine  could  be  readily  seen 
projecting  through  it.  In  the  neighborhood  of  the  umbilicus  there 
was  a  sense  of  increased  tenderness  on  deep  palpation,  and  the  re- 
sistance made  one  suspect  the  possibility  of  there  being  present  a 
tubercular  peritonitis  which  had  caused  an  exudation,  binding  the 
intestines  together  in  a  mass.    About  McBurney's  point  there  was 

Fig.  21. 


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A  case  of  typhoid  fever  preceded  by  appendicitis  (?),  or  by  a  primary  attack  of 

typhoid  fever. 

very  distinct  tenderness  on  palpation,  and  deep  palpation  produced 
severe  pain.  In  view  of  her  history,  her  emaciation,  and  the  symp- 
toms detailed,  I  was  inclined  to  consider  the  case  one  of  tubercular 
peritonitis,  or  else  one  of  appendicitis  of  the  subacute  or  chronic 
character,  with  a  tendency  to  exacerbations.  In  this  opinion  Pro- 
fessor Keen  agreed  with  me,  and  it  was  arranged  that  Professor 
Keen  should  perform  an  abdominal  section  for  the  purpose  of 
removing  the  appendix,  if  it  alone  was  the  cause  of  the  difficulty, 
or  of  relieving  her  tubercular  peritonitis  through  the  well-known 
beneficial  effects  of  abdominal  section.     On  the  day  on  which  she 


CONDITIONS  WHICH  APE  TYPHOID  FEVER.  259 

was  to  be  operated  upon,  her  temperature  having  been  normal 
for  a  number  of  days,  and  her  general  condition  having  steadily 
improved  under  treatment  designed  to  prepare  her  system  for 
operation,  she  developed  marked  languor  and  malaise  and  febrile 
movement,  which  is  shown  in  the  accompanying  chart  (Fig.  21), 
and  three  days  later  developed  typical  rose  rash  of  typhoid  fever, 
her  blood  giving  the  positive  Widal  reaction  simultaneously.  The 
questions  which  naturally  arise  in  regard  to  this  case  are  :  Did 
the  woman  suffer  primarily  from  appendicitis,  or  from  tubercular 
peritonitis,  or  did  she  come  under  my  care  at  the  end  of  a  mild 
primary  attack  of  typhoid  fever  after  which  she  had  a  relapse,  or, 
again,  is  it  possible  that  suffering  from  a  mild  chronic  intestinal 
catarrh,  she  received  typhoid  infection  just  prior  to  her  entering 
the  ward,  thereby  superimposing  typhoid  fever  upon  the  condi- 
tion present  when  we  first  saw  her?  Because  of  her  ultimate 
complete  recovery  I  am  inclined  to  believe  that  the  primary  fever 
could  not  have  been  due  to  tubercular  peritonitis. 

Another  interesting  case,  illustrating  how  difficult  these  differ- 
ential diagnoses  may  be,  is  reported  by  Dreschfeld  in  Allbutt's 
System  of  Medicine,  in  which  three  members  of  one  family  that 
had  lived  in  a  cellar  which  had  been  under  water  at  the  time  of 
an  extensive  flood  were  attacked  with  a  fever.  Their  symptoms 
closely  resembled  those  of  enteric  fever,  and  one  of  them  pre- 
sented on  the  third  day  after  admission  marked  roseolar  spots,  and 
had  slight  intestinal  hemorrhage  on  the  fifth  day.  The  tempera- 
ture showed  marked  exacerbations,  and  the  patient  died  from 
exhaustion  on  the  fourteenth  day  after  admission,  or  about  the 
seventeenth  day  of  the  fever.  The  post-mortem  examination 
revealed  the  intestines  apparently  healthy.  Dreschfeld  says  he 
can  quote  similar  cases.  He  does  not  state  what  he  believed  this 
illness  to  be  due  to,  but  from  the  context  he  evidently  regarded 
it  as  septic,  although  the  absence  of  intestinal  lesions,  as  I  have 
already  stated,  does  not  exclude  enteric  fever. 

Leu1  has  reported  a  case  of  puerperal  septicaemia    which  was 

1  ChariU'  Annalen,  1891,  vol.  xvi.  p.  315. 


260     COMPLICATIONS  AND  SEQUEL  JE  OF  TYPHOID  FEVER. 

almost  indistinguishable  froni  typhoid  fever,  for  the  patient  had  a 
rose  rash,  tympanites,  enlarged  spleen,  intestinal  infection,  and  the 
pyrexia!  curve,  which  is  characteristic.  The  fact  that  puerperal 
septicaemia  is  fatal  within  a  few  days  ;  that  there  is  a  local  focus 
of  the  disease,  and  that  such  a  disease  would  not  present  the 
Widal  reaction,  aids  us  in  making  a  differential  diagnosis. 

Another  condition  which  may  closely  simulate  enteric  fever  is 
the  gastro-intestinal  form  of  epidemic  influenza,  for  in  this  condi- 
tion we  have  enlargement  of  the  spleen,  diarrhoea,  tympanites, 
gurgling,  slight  evidences  of  bronchial  irritation,  and  very  rarely, 
indeed,  a  suspicious  roseolar  rash.  On  the  other  hand,  it  is  per- 
fectly possible  for  enteric  fever  and  influenza  to  occur  simulta- 
neously in  the  same  patient. 

Under  the  name  of  mountain  fever,  a  febrile  disease  occurring 
in  the  great  highlands  which  occupy  the  middle  portion  of  the 
United  States,  has  been  described  by  a  number  of  authors.  Some 
of  these  writers  have  been  strongly  of  the  opinion  that  mountain 
fever  is  a  distinct  entity,  while  others  have  gone  so  far  as  to  assert 
that  it  is  an  irregular  manifestation  of  malarial  poisoning,  and 
still  others  that  it  is  a  modified  form  of  typhoid  fever. 

As  a  matter  of  fact,  we  may  state  positively  at  this  time  that 
true  mountain  fever  is  in  all  cases  nothing  more  than  a  greatly 
modified  or  altered  type  of  typhoid  infection.  As  has  already 
been  pointed  out  in  this  essay  a  number  of  times,  typhoid  fever 
is  a  disease  which  varies  greatly  in  its  symptomatology  and  course, 
and  does  not,  in  many  instances,  follow  the  classical  descriptions 
of  it  which  we  are  accustomed  to  find  in  the  text-books. 

One  of  the  most  conclusive  and  interesting  papers  dealing  with 
this  matter  which  is  to  be  found  in  recent  literature,  is  that  of 
Raymond,  who,  as  post  surgeon  at  one  of  the  United  States 
Army  stations  in  the  West,  has  contributed  to  the  American  Jour- 
nal of  the  Medical  Sciences,  1898,  vol.  cxv.,  an  exhaustive  paper 
upon  this  subject. 

Quinine  administered  to  these  cases,  in  full  doses,  failed  to  exer- 
cise any  beneficial  effect ;  prophylactic  measures,  which  are  ordi- 
narily successful  in  the  control  of  the  typhoid  epidemic,  at  once 


CONDITIONS  WHICH  APE  TYPHOID  FEVER.  261 

checked  the  disease,  and  a  comparison  of  many  of  the  symptoms 
manifested  with  those  met  with  in  irregular  forms  of  typhoid 
fever  still  further  indorse  the  view  we  have  already  expressed  in 
regard  to  the  unity  of  these  two  diseases. 

These  views  in  regard  to  mountain  fever  are  also  supported  by 
the  paper  of  Work/  who  tells  us  that  eighteen  out  of  fifty  cases 
of  mountain  fever,  so  called,  had  rose  spots,  and  that  in  five  fatal 
cases  the  intestinal  lesions  of  the  fever  were  found. 

The  differential  diagnosis  of  typhoid  fever  in  children  from  the 
other  exanthemata  is  made  as  follows  :  From  scarlet  fever  by  the 
pain  in  the  back,  the  excited  nervous  system,  the  eruption  on  the 
second  day,  and  the  absence  of  pain  in  the  abdomen,  and  the  stupor 
of  enteric  fever.  There  is  usually  in  scarlet  fever,  too,  great  sore- 
throat.  From  measles  we  are  apt  to  have  greater  bronchial  catarrh, 
at  least  at  first  ;  coryza,  which  is  very  rare  in  typhoid  fever,  and 
an  early  eruption.  From  entero-colitis  we  distinguish  enteric 
fever  by  the  absence  of  delirium  or  stupor  in  this  affection,  and 
the  character  of  the  diarrhoea,  as  well  as  the  greater  abdominal 
tenderness.  The  value  of  the  Widal  test  in  these  cases  is  never 
to  be  forgotten. 

1  Medical  News,  April  8,  1894. 


CHAPTER    VI. 

DURATION  AND  IMMUNITY  TO  SECOND  ATTACKS. 

The  duration  of  typhoid  fever  varies  greatly  in  different  indi- 
viduals, and  still  more  so  in  different  epidemics,  depending  upon 
the  vital  resistance  of  the  patient  and  the  virulency  of  the  infection. 
It  may,  however,  be  asserted  that  the  average  period  of  fever  is 
twenty-one  days,  although  wide  variations  from  this  may  occur,  the 
duration  being  much  less  or  much  greater,  as  already  pointed  out. 

Murchison  states  the  mean  duration  in  seventy-five  cases  to 
be  a  fraction  more  than  twenty-four  days.  Flint  states  from 
going  to  bed  to  normal  temperature  sixteen  days,  with  a  maximum 
of  twenty -eight  days  and  a  minimum  of  five  days.  The  longest 
case  seen  by  Flint  was  fifty-eight  days. 

Of  forty-five  of  Flint's  fatal  cases  the  duration  was  a  fraction 
more  than  fourteen  days.  Murchison  tells  us  that  the  mean  stay 
in  the  hospital  of  500  cases  which  recovered  was  31.24  days ;  of 
100  fatal  cases,  16.52  days,  while  the  average  duration  of  illness 
before  admission  of  the  600  cases  was  10.78  days.  Again,  Mur- 
chison tells  us  that  the  pyrexia,  as  a  rule,  lasts  at  least  three 
weeks,  and  the  ordinary  duration  of  enteric  fever  is  from  three  to 
four  weeks.  Of  200  cases  which  recovered,  and  in  which  he  was 
able  to  fix  the  commencement  with  tolerable  certainty,  the  dura- 
tion was  :  10  to  14  days  in  7  cases ;  15  to  21  days  in  49  cases ; 
2  to  28  days  in  111  cases ;  29  to  35  days  in  33  cases. 

The  mean  duration  of  the  200  cases  was  24.3  days,  and  the 
mean  duration  of  112  other  cases,  which  were  fatal,  was  27.67  days. 

The  average  duration  of  residence  in  St.  Thomas'  Hospital, 
London,  in  1894,  1895,  and  1896,  was  from  43.1  to  51.8  days, 
and  the  average  duration  of  fever  from  14.3  to  16.73  days, 
although  a  great  proportion  of  the  patients  were  admitted  in  the 
first  or  second  week. 


DURATION  AND  IMMUNITY  TO  SECOND  ATTACKS.     263 

In  the  Maidstone1  epidemic,  8  per  cent,  lasted  two  weeks ;  27 
per  cent.,  three  weeks;  31  per  cent.,  four  weeks;  17  per  cent., 
five  weeks ;  8  per  cent.,  six  weeks ;  4.5  per  cent.,  seven  weeks ; 
84.5  per  cent.,  eight  weeks. 

If  we  take  the  twenty-five  cases  admitted  in  the  first  week  of 
the  disease  given  in  Wilson's  table,  we  find  that  the  average  stay 
of  these  patients  in  the  house  was  forty-one  days  (40-f),  and  the 
average  day  of  normal  temperature  the  nineteenth.  The  average 
maximum  temperature  was  104.6°  If  the  entire  108  cases 
given  in  his  last  table  in  his  article  are  studied,  we  find  that  the 
average  duration  of  the  fever  was  in  the  cases  admitted  in  the 
second  week,  23.2  days ;  in  the  third  week,  27.3  days,  and  the 
average  stay  in  the  house  of  the  second-week  cases,  40.8  days,  and 
of  the  third-week  cases,  38.8  days. 

While  the  general  average  may  be  about  twenty-one  days,  very 
much  shorter  periods  have  been  seen  and  noted  by  every  physician 
of  experience,  and  very  important  classifications  of  cases  have 
been  made  by  Liebermeister  and  Jurgensen.  The  first  of  these 
clinicians  speaks  of  the  mildest  cases  as  those  in  which  the  rectal 
temperature  never  or  rarely  rises  above  103°,  and  the  duration  of 
fever  does  not  exceed  eight  days.  The  mild  cases  do  not  have  a 
rectal  temperature  above  104.8°,  and  the  fever  lasts  sixteen  days. 
The  severe  cases  are  those  in  wliich  the  rectal  temperature  rises 
above  105°  and  the  fever  ceases  by  the  twenty-first  day.  Jur- 
gensen considers  all  cases  mild  which  have  no  fever  after  the 
tenth  day,  and  those  severe  that  have  fever  after  this  date ;  but 
this  view  hardly  coincides  with  that  of  American  physicians,  who 
regard  a  fever  ending  by  the  twenty-first  day  as  quite  moderate, 
particularly  if  the  fever  does  not  exceed  104°. 

There  is  one  class  of  patients  in  which  the  febrile  movement 
very  commonly  lasts  but  a  week  or  two,  namely,  children.  Henoch 
stated  years  ago  that  out  of  80  cases  seen  by  him  there  were  11 
which  lasted  7  to  10  days  ;  26  from  10  to  15  days  ;  16  from  15  to 
20  days  ;    21   from  20  to  30  days,  and   6   from  30  to  49  days. 

1  Poole.     Guy's  Hospital  Keports,  1898.     Wrongly  labelled  on  cover,  1896. 


264     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

Even  in  the  cases  lasting  but  a  week  or  ten  days  there  were  ro- 
seola, enlargement  of  the  spleen,  and  diarrhoea.  In  confirmation 
of  this  view,  we  have  the  more  recent  observations  of  Forchheimer, 
of  Cincinnati,  who  found  in  an  epidemic  of  this  malady  among 
children  that  the  fever  may  terminate  as  early  as  the  sixth  day, 
and  Janeway,  of  New  York,  remarks  that  it  may  end  in  ten  days. 
It  is  evident,  therefore,  that  the  duration  of  typhoid  fever  in 
children  is  shorter  than  in  adults,  as  a  rule,  as  well  as  milder 
in  the  character  of  its  manifestations,  and  that  it  is  accompanied 
by  less  grave  intestinal  lesions. 

Musser  has  recorded  the  case  of  typhoid  fever  in  which,  though 
there  were  no  complications,  the  temperature  did  not  reach  normal 
until  seventy-three  days  had  elapsed. 

In  children  convalescence  is  even  more  prolonged  than  it  is  in 
adults  in  some  cases.  As  long  ago  as  1839,  Taupin1  emphasized 
this  fact,  stating  that  pallor,  feebleness,  and  general  debility  are 
marked. 

The  question  of  the  frequency  of  second  attacks  of  typhoid 
fever  is  of  interest.  It  is  generally  considered  that  an  attack 
renders  a  patient  at  least  partially  immune  to  other  attacks. 
Moore2  has  recorded  a  case  of  a  man  who  suffered  from  typhoid 
fever  at  fifteen  years  and  again  at  twenty-nine  years,  and  finally 
from  a  relapse  after  this  second  attack,  and  Leidy3  has  reported  a 
case  of  a  boy  who  had  an  attack  of  enteric  fever  at  sixteen  years, 
a  second  attack  six  months  later,  a  third  at  the  age  of  thirty-four 
years,  and  this  followed  by  four  relapses,  in  the  third  of  which  he 
had  intestinal  hemorrhage,  but  recovery  nevertheless  occurred. 
During  the  winter  of  1897-98  the  writer  had  under  his  care  a 
boy  who  was  suffering  from  his  third  attack  of  typhoid  fever,  his 
first  having  occurred  at  nine  years  of  age,  the  second  at  seventeen 
years,  and  the  third  at  nineteen  years.  Death  occurred  from  hem- 
orrhage of  the  bowels.  In  1626  cases  Bey  found  only  one  which 
had  a  second  attack. 

1  Journal  des  Connaissance  Me"d.  Chirurgicale,  July,  1839. 

2  Dublin  Journal  of  Medical  Science,  April,  1893. 

3  International  Medical  Magazine,  August,  1893. 


CHAPTER    VII. 

THE  MENTAL  COMPLICATIONS.1 

The  mental  complications  of  typhoid  fever  resemble  in  a  gen- 
eral way  the  mental  disorders  resulting  from  other  infectious 
diseases.  They  occur  by  preference  in  patients  in  whom  there  is 
present  a  neurotic  heredity  or  who  have  been  subjected,  previous 
to  infection,  to  overwork,  loss  of  sleep,  anxiety,  or  other  exhaust- 
ing nervous  strains.  Hereditary  factors — functional  neuroses  and 
insanities — appear  to  be  present  in  about  half  the  cases.  It  can- 
not be  claimed,  however,  that  the  other  predisposing  causes  possess 
much  etiological  value,  as  mental  complications  frequently  occur  in 
individuals  in  which  these  factors  have  been  absent.  Sex  appears 
not  to  exercise  any  predisposing  influence,  males  and  females 
being  affected  in  about  equal  number.  Age,  also,  is  not  a  deter- 
mining factor.  It  is,  however,  somewhat  significant  that  typhoid 
fever  attacks  by  preference  individuals  of  an  age  at  which  mental 
disorders  are  very  prone  to  occur,  namely,  youth  and  early  adult 
life.  Notwithstanding,  mental  diseases  of  typhoid  origin  of  suffi- 
cient severity  to  demand  asylum  treatment  do  not  appear  to  be  as 
frequent  as  this  coincidence  would  suggest.  Thus  Nasse  reported 
43  cases  among  2000  hospital  admissions ;  Schlager,  22  cases  in 
500  ;  Christian,  11  in  2000,  while  Pilgrim  found  only  13  cases  in 
over  6000  admissions.  We  should  remember,  however,  that  hos- 
pital statistics  cannot  be  regarded  as  in  any  sense  representing  the 
real  frequency  of  these  disorders.  First,  a  large  number  of  cases 
do  not  necessitate  commitment,  and,  secondly,  in  hospital  admis- 
sions the  etiological  relation  with  typhoid  fever  is  not  always 
brought  to  the  attention  of  the  asylum  physicians. 

1  By  F.  X.  Dercum,  M.D.,  Clinical  Professor  of  Diseases  of  the  Nervous  Sys- 
tem in  the  Jefferson  Medical  College. 


266     COMPLICATIONS  AND  SEQUEL M  OF  TYPHOID  FEVER. 

The  occurrence  of  typhoid  insanities  appears  to  depend,  among 
other  things,  on  the  character  of  the  individual  epidemic  ;  they 
occur  more  frequently  in  some  epidemics  than  in  others.  Among 
special  factors  it  is  not  improbable  that  constipation  may  be  a  pre- 
disposing cause,  by  favoring  the  retention  and  absorption  of  poisons. 

The  mental  disturbances  of  typhoid  fever  are  separable  into 
three  groups  :  First,  those  which  develop  during  the  prodromal  or 
initial  period ;  secondly,  those  which  arise  during  the  continuance 
of  the  fever,  and,  thirdly,  those  which  occur  during  or  subsequent 
to  convalescence. 

The  affections  occurring  during  the  prodromal  period  cannot  be 
definitely  separated  from  those  occurring  during  the  initial  period 
of  the  fever,  inasmuch  as  cases  beginning  in  the  prodromal  period 
may  persist  after  fever  has  made  its  appearance.  They  manifest 
themselves  in  one  of  two  forms  :  First,  a  form  in  which  mental 
depression  or  mental  excitement  is  the  leading  feature,  and,  sec- 
ondly, a  form  in  which  the  symptoms  are  those  of  an  acute  deli- 
rium. The  first  is  represented  by  a  class  to  which  Campbell1  calls 
attention.  They  begin  in  the  prodromal  period,  and  are  especially 
prone  to  occur  when  this  period  is  protracted.  They  appear  to  be 
directly  related  to  the  malaise  and  degree  of  nervous  prostration. 
Thev  are  not  infrequently  met  with  in  those  cases  in  which  the 
fever  is  slow  in  making  its  appearance  or  does  not  become  pro- 
nounced until  a  considerable  time  has  elasped.  They  are  character- 
ized by  mental  depression,  less  frequently  by  mental  excitement, 
associated  with  disordered  mental  action — probably  confusion,  with 
some  hallucinations.  It  is  not  surprising  that  the  mental  condi- 
tion may  entirely  mask  the  underlying  disease.  The  symptoms 
may  be  so  pronounced  as  to  lead  to  the  commitment  of  the  patient 
to  the  asylum,  the  nature  of  the  case  not  becoming  evident  until 
later.  It  is  extremely  probable  that  in  such  cases  there  is  a 
marked  hereditary  tendency  to  insanity,  and  that  the  depression 
of  the  prodromal  period  of  the  fever  merely  acts  as  an  exciting 
cause.     It  should  be  added  that  these  cases  are  quite  rare.     We 

1  Campbell, Colin  M.     Diet,  of  Psycholog.  Med.,  vol.  i.  p.  506. 


THE  MENTAL  COMPLICATIONS.  m  267 

should,  however,  remember  that  if  a  given  case  is  ulwuiv  in  its 
origin,  if  the  mental  depression  has  developed  in  a  manner  more 
rapidly  than  that  seen  in  melancholia,  and  if  it  is  otherwise  atyp- 
ical, the  commitment  should,  if  possible,  be  delayed  and  the  case 
be  kept  under  observation  for  some  days.  The  occurrence  of  this 
form  also  shows  how  important  it  is  to  make  a  thorough  physical 
examination  of  the  patient. 

'  In  the  second  form  of  mental  disorder  of  the  prodromal  or 
initial  period,  Ave  have  present,  as  already  stated,  the  symptom-  of 
an  acute  delirium.  This  delirium  is  characterized  by  profound 
mental  obtusion,  confusion,  and  hallucinations,  Avhich  are  often 
terrifying  in  character.  There  are  manifestations  of  great  fear 
and  often  impulses  to  violent  acts.  In  this  form  violent  assault 
upon  the  person,  murder,  or  suicide  may  occur.  It  may,  indeed, 
in  rare  cases  attain  the  violence  of  typho-mania1  (delirium  grave). 
(See  chapter  on  onset.)  While  the  delirium  is  usually  accom- 
panied by  terrible  hallucinations,  the  patient  seeing  frightful  ob- 
jects and  hearing  terrifying  sounds,  it  is  under  rare  circumstances 
associated  with  expansive  ideas.  Kirn2  describes  a  case  in  which 
instead  of  depression  there  was  present  delirium  of  grandeur,  only, 
however,  to  be  followed  by  depression  later  on. 

The  acute  delirium  of  the  initial  period  is  to  be  looked  upon  as 
among  the  unusual  mental  complications  of  typhoid  fever.  It 
appears  to  be  present  especially  in  certain  epidemics,  as,  for 
instance,  in  that  recorded  by  Blanc3  as  occurring  among  French 
troops  in  Tunis.  Whether  the  delirium  actually  antedates  the 
outbreak  of  fever  is  uncertain,  inasmuch  as  accurate  temperature 
studies  are  as  yet  lacking.  It  may,  however,  continue  for  some 
time  after  the  fever  has  been  established,  and  may  merge  into  the 
ordinary  fever  delirium.  In  other  cases,  again,  it  disappears  alto- 
gether as  the  height  of  the  fever  is  reached.  Many  cases,  how- 
ever, die  before  the  fever  has  fully  developed.  The  existence  of 
acute  delirium  in  the  prodromal  or  the  initial  period  of  typhoid 

1  Xasse.     Allegemeine  Zeitschr.,  f.  Psych.,  1870-71,  p.  11. 

2  Ibid.,  vol.  xxxix.  p.  741.  3  Schmidt's  Jahrbucher,  vol.  ccxiv. 


268     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

fever  is  always  to  be  looked  upon  as  of  ill  omen.  According  to 
Adler,1  only  one-third  of  the  cases  presenting  this  complication 
recover. 

The  mental  complications  occurring  during  the  period  of  fever 
separate  themselves  into,  first,  the  ordinary  fever  delirium  ;  second, 
expansive  or  ambitious  delirium,  and,  third,  stupor  or  coma  vigil. 
The  fever  delirium  is  ordinarily  quiet  in  type,  and,  though  at  times 
associated  with  excitement,  does  not  merit  separate  consideration 
here.  The  expansive  or  ambitious  delirium,  a  rare  form  of  com- 
plication, may  be  present  during  the  entire  course  of  the  fever. 
More  frequently  it  comes  on  after  the  fever  has  passed  its  height, 
and  persists  during  the  period  of  decline.  In  such  cases  the 
patient  presents  the  picture  of  the  delirium  of  grandeur.  In  a 
case  observed  by  the  writer  the  patient  kept  talking  about  his 
bags  and  vaults  of  gold,  about  his  diamonds,  fast  horses,  and  other 
great  worldly  possessions.  The  delirium  is  not  accompanied  by 
marked  excitement,  and  disappears  with  the  defervescence  of  the 
fever.2 

The  stupor  of  typhoid  fever,  like  the  ordinary  fever  delirium,  is 
so  well  known  as  not  to  merit  description.  It  may  come  on  as  a 
gradual  deepening  of  the  initial  apathy  and  hebetude  of  the  dis- 
ease, or  may  be  a  transition  from  the  fever  delirium.  More  rarely 
it  is  the  outcome  of  an  acute  delirium  of  the  initial  period.  Its 
occurrence  at  an  early  stage  is  always  of  grave  significance. 
When  arising  during  the  period  of  decline  it  sometimes  continues 
long  after  the  fever  has  subsided. 

The  insanities  which  arise  during  or  subsequent  to  convales- 
cence are  those  which  principally  concern  us  here.  They  may 
arise  during  the  subsidence  of  the  fever,  and  may  be  merely  a 
continuation  of  the  confusion  and  delirium  of  the  febrile  stage ; 
much  more  frequently  they  make  their  appearance  after  the  fever 
has  entirely  disappeared. 

1  Allegemeine  Zeitschr.  f.  Psych.,  vol.  liii.  p.  753. 

2  Cases  have  been  reported  by  Delasiauve,  Christian,  Simon,  and  Liouville. 
Diet,  of  Psycholog.  Med.  vol.  ii.  p.  986. 


THE  MENTAL  COMPLICATIONS.  269 

Post-typhoid  insanities  may  make  their  appearance  in  one  or 
other  of  the  following  forms  : 

1.  Acute  delirium. 

2.  Confnsional  insanity,  stuporous  insanity.1 

3.  Cerebral  asthenia,  pseudo-dementia,  pseudo-paresis. 

4.  Insanity  with  systematized  delusions  resembling  paranoia. 

5.  True  melancholia  or  true  mania. 

1.  Acute  Delirium.  The  acute  delirium  following  typhoid 
fever  is  indistinguishable  from  the  delirium  of  exhaustion  follow- 
ing other  infectious  fevers,  shock,  trauma,  or  other  profoundly 
debilitating  causes.  It  is  characterized  by  excessive  mental  con- 
fusion, increased  rapidity  in  the  flow  of  ideas,  numerous  and  varied 
hallucinations,  obtusion  of  the  perceptive  faculties  to  both  internal 
and  external  impressions,  and  marked  motor  excitement.  The 
onset  is  usually  sudden,  and  frequently  corresponds  with  the  termi- 
nation of  the  fever.  It  appears  to  coincide  with  the  collapse 
which  follows  the  disappearance  of  the  fever  in  some  cases.  At 
other  times  a  brief  interval  of  a  day  or  two  characterized  by 
insomnia  and  ominous  restlessness  precedes  the  outbreak.  Con- 
sciousness becomes  much  obscured ;  the  patient  loses  the  proper 
recognition  of  his  surroundings  ;  he  becomes  illusional,  everything 
seems  strange  and  changed,  and  in  addition  he  becomes  hallucina- 
tory to  an  extreme  degree.  The  chairs  and  other  objects  of  furni- 
ture are  mistaken  for  strange  shapes,  persons,  or  animals.  The 
individuals  about  his  bed  are  no  longer  properly  recognized  ;  the 
pictures  upon  the  walls,  the  curtains  upon  the  windows,  the  rugs 
upon  the  floor  all  become  animate  objects.  The  hallucinations 
rival  the  illusions  in  their  variety  and  number.  They  appear  to 
consist  especially  of  auditory  and  visual  sensations.  Voices  call 
to  him,  strange  persons,  horrid  creatures  gesticulate,  beckon,  ter- 
rify him.      It  is  not  strange   under  these  circumstances  that  he 

1  Kraepelin,  Lehrbuch  Psychiatrie,  is  one  of  the  few  systematic  writers  to  fully 
appreciate  the  etiological  relation  of  typhoid  fever  to  these  disorders.  Paglians, 
Revue  de  Med.,  1894,  xiv.  549  and  656,  unfortunately  misinterprets,  as  did  the 
older  writers,  post-typhoid  conditions  attended  by  excitement  or  depression  as 
mania  or  melancholia. 


270     COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER. 

appears  to  have  dreadful  and  depressive  delusions.  He  believes 
that  horrible  punishments  are  to  be  meted  out  to  him ;  that  he  is 
to  be  cut,  to  be  stabbed,  to  be  poisoned,  that  he  has  only  a  short 
time  to  live.  No  wonder  that  his  struggles  are  often  merely  the 
outward  expression  of  a  frenzied  fear.  Very  rarely  the  halluci- 
nations and  the  delusions  are  of  a  pleasurable  and  expansive 
character,  the  patient  showing  by  his  demeanor,  as  well  as  by  his 
speech,  the  pleasure  that  he  feels.  Sometimes  he  is  distinctly 
erotic.  Occasionally  depressive  and  expansive  mental  states  are 
present  at  different  times  in  the  same  case. 

The  speech  of  the  patient,  in  keeping  with  his  disturbed  mental 
condition,  is  for  the  most  part  fragmentary  and  confused,  and 
the  delusive  ideas  are  difficult,  if  not  impossible,  to  follow.  Of 
course,  the  delusions  themselves  are  fragmentary  and  unsystem- 
atized. The  patient  cries  out  or  utters  merely  parts  of  sentences 
and  phrases,  and  when  the  condition  is  fully  established  his 
words  may  be  entirely  incoherent  or  consist  of  senseless  allit- 
erations. At  other  times  he  talks  excitedly,  loudly,  pathetically, 
or  whispers,  gesticulates,  and  makes  grimaces.  It  is  generally 
impossible  to  obtain  a  rational  answer  to  a  question,  though  some- 
times during  a  momentary  lull  the  patient  may  comply  with  a 
given  direction.  The  well-meant  attentions  of  the  nurse  and 
friends  are  misunderstood  and  generally  actively  resisted.  Sleep 
is  almost  abolished ;  indeed,  completely  so  in  some  cases  during 
the  entire  attack.  Food  and  medicine  are  administered  with  great 
difficulty.  When  the  food  is  placed  in  the  mouth  the  patient  may 
spit  it  out,  though  in  other  cases  it  may  be  greedily  swallowed. 
As  the  delirium  reaches  its  height  the  mind  becomes  more  and 
more  confused,  and  the  motor  excitement  manifests  itself  in  sense- 
less struggling  or  in  purposeless  and  automatic  movements,  turn- 
ing about  the  bed,  aimless  gestures,  pushing,  rubbing,  etc. 

The  physical  condition  is  indicative  of  great  weakness,  the  color 
is  pale,  the  surface  of  the  body  is  cold  and  often  moist,  and  the 
emaciation  of  the  typhoid  fever  is  rapidly  and  greatly  accentuated. 
The  pulse  is  small,  sometimes  slow,  sometimes  rapid ;  it  is  always 
weak.    As  a  rule,  abrasions  and  ecchymoses  are  observed  on  vari- 


THE  MENTAL  COMPLICATIONS.  271 

ous  parts  of  the  body.  Generally  they  arc  the  unavoidable  results 
of  the  patient's  struggles. 

Acute  delirium  is  a  complication  of  short  duration.  It  may 
last  only  a  few  hours  ;  it  never  extends  over  more  than  a  few 
days.  Recovery  is  ushered  in  by  the  return  of  consciousness, 
which  is  generally  quite  rapid.  The  patient  begins  to  recognize 
his  surroundings  and  his  hallucinations  disappear.  He  begins  to 
comply  with  the  directions  of  the  nurse,  takes  his  food  and,  above 
all,  begins  to  sleep.  As  a  rule,  the  recovery  is  steady  and  unin- 
terrupted ;  but  at  times  it  is  broken  in  upon  by  recurrences  of  the 
delirium,  generally  transient  in  character.  Recovery  does  not, 
however,  always  ensue.  The  exhaustion  may  proceed  so  far  as  t<» 
lead  to  stupor,  and  the  patient  may  remain  in  this  condition  for  a 
prolonged  period  of  time.  The  final  prognosis,  however,  of  even 
this  form  of  complication  is  relatively  good.  The  great  majority 
of  cases  of  acute  delirium  following  typhoid  fever  recover.  How- 
ever, emotional  irritability  and  instability,  hebetude,  and  physical 
weakness  persist  for  several  weeks  after  the  delirium  has  ceased. 
The  memory  of  the  patient  for  the  events  of  the  attack  is  much 
obscured.  He  can  seldom,  if  ever,  give  any  but  a  vague  account 
of  his  experiences. 

A  word  of  caution  may  not  be  out  of  place  here  in  regard  to 
the  too  free  use  of  alcohol  in  the  treatment  of  typhoid  fever. 
The  writer  once  saw  in  consultation  a  child  in  which  the  delirium 
proved  not  to  be  a  sequel  of  the  fever,  but  was  really  due  to 
the  large  quantities  of  alcohol  which  had  been  administered.  A 
marked  and  typical  alcoholic  multiple  neuritis,  sthenic  in  character 
and  exquisitely  painful,  was  also  present. 

2.  Confusional  Insanity.  The  second  form  of  post-typhoid 
insanity  to  claim  our  attention  is  confusional  insanity.  Like  the 
acute  delirium  following  typhoid  fever  it  closely  resembles  the 
confusion  resulting  from  other  infectious  and  exhausting  diseases. 
It  is  characterized  by  obtusion,  mental  confusion,  incoherence  of 
ideas,  illusions,  hallucinations,  and  by  a  prolonged  course.  It  is 
much  more  frequently  met  with  as  a  sequel  of  typhoid  fever  than 
acute  delirium.     Typhoid  fever  most  frequently  induces  exhaustion 


272     COMPLICATIONS  AND  SEQUELJE  OF  TYPHOID  FEVER. 

gradually  ;  it  is  only  in  exceptional  cases  in  which  this  exhaustion 
comes  on  suddenly  that  acute  delirium  ensues.  In  by  far  the 
larger  number  of  cases  the  more  slowly  acting  causes  induce  the 
more  gradual  developing  and  more  prolonged  affection  we  are 
about  to  consider.  In  keeping  with  these  statements  the  onset  is 
much  less  rapid  than  in  acute  delirium.  It  does  not  make  its 
appearance  until  some  days  after  the  fever  has  subsided ;  gener- 
ally, however,  within  the  first  week.  The  patient  becomes  ner- 
vous, restless,  and  cannot  sleep.  Soon  he  becomes  unaccountably 
afraid  and  excited,  fears  impending  trouble  or  death,  is  obtuse, 
fails  to  comprehend  readily,  often  complains  that  he  cannot  think, 
and  he  readily  becomes  confused.  After  several  days  the  symp- 
toms become  so  pronounced  that  the  patient  begins  to  lose  the 
correct  appreciation  of  his  surroundings,  or  of  the  circumstances 
in  which  he  is  placed.  He  no  longer  knows  where  he  is,  mistakes 
the  people  about  him  for  strangers,  and  often  begs  piteously  to  be 
taken  home.  To  the  illusions  are  soon  added  hallucinations.  He 
hears  threatening  voices,  shouts,  and  cries.  He  sees  frightful 
objects  or  horrible  looking  men  who  load  him  with  abuse  and 
curses.  As  in  acute  delirium,  the  patient  now  believes  that  he  is 
being  injured,  that  serious  bodily  harm  is  about  to  be  done  him, 
that  he  is  to  be  beaten,  crushed,  killed.  In  addition  the  illusions 
also  play  an  important  part,  even  greater  than  the  hallucinations. 
The  patient  in  his  condition  of  fear  is  excessively  Avatchful  of  his 
surroundings,  which  he  constantly  misinterprets.  The  commonest 
objects  are  misunderstood — a  spoon  is  taken  for  a  knife,  a  ther- 
mometer inspires  deadly  fear,  a  hypodermic  injection  is  regarded 
as  a  savage  onslaught  with  a  dagger.  The  patient  also  catches 
words  and  phrases  uttered  by  the  bystanders  with  surprising 
readiness,  always,  of  course,  to  misinterpret  them.  For  this 
reason  it  is  well  not  to  whisper  in  the  patient's  presence,  nor  to 
make  unnecessary  gestures,  nor  to  move  about  the  room  mysteri- 
ously. 

Sometimes  it  is  possible,  by  speaking  distinctly  and  loudly,  to 
attract  the  patient's  attention  for  a  short  time.  Feeding,  when 
possible,  can  be  accomplished  by  this  means.    The  food  should  be 


THE  MENTAL  COMPLICATIONS.  273 

urged  upon  the  patient  by  speech,  by  the  proper  presentation  of 
food  to  vision  and  to  the  lips.  Frequently,  however,  it  is  impos- 
sible for  many  hours  at  a  time  to  bring  the  patient  to  himself  or 
to  a  realization  of  his  surroundings  by  any  means  whatever. 

Although  the  hallucinations  are  most  frequently  of  a  terrifying 
and  depressing  character,  they  are  not  necessarily  so.  In  rare 
instances  they  are  pleasurable,  and  the  patient  may  talk  in  a  dis- 
connected way  about  his  wealth,  the  beauty  and  grandeur  of  his 
surroundings,  and  the  glorious  future  that  lies  before  him.  Such 
expansive  ideas  also  are  now  and  then  found  in  an  intercurrent 
manner  in  the  ordinary  depressive  form.  In  keeping  with  these 
facts  the  emotional  state  is  usually  one  of  depression  and  appre- 
hension, infrequently  one  of  slight  exaltation.  Laughing  and 
singing  are  sometimes  interspersed  with  the  manifestations  of 
fear,  and  at  times  slight  eroticism  is  noticed. 

The  thoughts  are  disordered  and  tangled,  while,  as  in  the  acute 
delirium,  there  is  almost  always  some  increase  in  the  rapidity  of 
the  flow  of  ideas.  Consciousness,  as  already  stated,  is  much 
obtunded ;  frequently  it  is  dream-like.  More  or  less  motor  ex- 
citement is  always  present.  It  is,  however,  much  less  marked 
than  in  the  delirium.  The  patient  is  restless,  tries  to  get  out  of 
bed,  tries  to  run  about  the  room,  struggles  at  times  to  get  away, 
and  may  exhibit  some  tendency  to  violence.  In  some  cases  there 
is  relative  quiet  from  muscular  weakness  or,  perhaps,  from  inhi- 
bition. In  others  the  patient  holds  fast  in  a  senseless  sort  of  man- 
ner to  surrounding  objects  or  persons,  or  resists  in  a  semi-passive 
way  the  attentions  of  the  nurse.  In  other  cases,  again,  he  betrays 
evidences  of  automatism  and  tends  to  remain  for  some  time  in  the 
position  in  which  he  has  been  placed.  Symptoms  such  as  these, 
however,  are  relatively  infrequent. 

The  speech  varies  considerably.  Sometimes  whole  sentences  are 
littered,  at  other  times  merely  phrases,  fragments,  or  incoherent  and 
disjointed  words.  It  is,  however,  much  easier  to  gain  some  idea 
of  the  character  of  the  delusions  which  pass  through  the  patient's 
mind  than  in  acute  delirium;  there  they  are  largely  a  matter  of 
inference,  here  they  are  often  more  or  less  plainly  expressed.      As 

18 


274     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

might  be  expected,  sleep  is  much  disturbed.  Insomnia  is  always 
marked,  especially  at  night.  Food  is  taken  badly,  partly  because 
it  is  not  properly  recognized  and  partly  because  of  fear  and  the 
suspicion  of  poisoning  ;  the  latter  idea  has  its  groundwork  largely 
in  illusions  and  hallucinations  of  taste  and  smell. 

The  physical  condition  of  the  patient  is,  as  a  rule,  bad.  Loss 
of  flesh  is  marked,  though  rarely  as  striking  as  in  acute  delirium. 
The  surface  is  cool,  the  extremities  often  cold,  sometimes  moist. 
The  temperature  is  not  infrequently  subnormal,1  though  it  may  be 
normal  throughout.  The  pulse  is  slow  and  lacks  force.  Now  and 
then  there  is  incontinence.  The  reflexes,  when  they  can  be 
studied,  are  usually  found  exaggerated. 

The  symptoms  attain  a  maximum  in  from  two  to  three  weeks 
after  the  actual  onset.  The  subsequent  course  is  apt  to  be 
irregular,  the  confusion  becoming  more  or  less  marked  by  turns  ; 
the  periods  of  temporary  improvement  often  correspond  to  the 
taking  of  increased  amounts  of  food,  or  follow  more  or  less  suc- 
cessful periods  of  sleep.  Convalescence  generally  sets  in  very 
gradually.  Generally  many  weeks  elapse  before  persistent  im- 
provement is  noted.  The  patient  begins  for  short  periods  of  time 
to  properly  appreciate  his  surroundings  and  to  understand  what  is 
said  to  him.  The  periods  of  lucidity  gradually  become  prolonged 
until,  from  being  merely  of  a  few  hours'  duration,  they  last 
through  the  greater  part  of  the  day.  During  the  convalescence 
the  patient  is  often  irritable  and  hard  to  please.  Sometimes  traces 
of  the  old  distrust  and  suspicion  are  seen ;  the  patient  makes 
absurd  charges  against  his  nurse,  or  is  obstinate  and  intractable. 
Gradually,  however,  he  becomes  more  sensible,  more  friendly,  and 
begins  to  manifest  confidence  in  those  about  him.  In  many 
instances,  too,  during  this  period,  the  patient  is  mildly  excited  or 
depressed,  while  in  others  some  of  the  hallucinations  persist  after 
lucidity  has  made  its  appearance,  but  in  such  case  the  latter  are 
no  longer  made  the  basis  of  delusions.  Rarely,  however,  fleeting 
delusions  now  and  then  betray  themselves.     A  valuable  index  as 

1  Wood.     University  Medical  Magazine,  Dec,  1889,  vol.  ii.  p.  117. 


THE  MENTAL  COMPLICATIONS.  275 

to  impending  convalescence  is  the  willingness  of  the  patient  to 
take  food.  Partial  relapses,  it  should  be  added,  also  occur,  espe- 
cially as  the  result  of  emotional  excitement,  the  visits  of  impor- 
tunate and  mistaken  friends,  or  other  imprudent  management. 
The  time  occupied  by  the  course  of  the  disease  varies  from  six 
weeks  to  four  months,  and  sometimes  longer.  Even  after  recov- 
ery appears  to  have  taken  place  the  patient  may  betray  decided 
mental  weakness  and  readiness  of  fatigue.  This  asthenia  is  often 
prolonged,  and  may  persist  for  months  and,  exceptionally,  even 
for  a  year  or  more.  Death  as  a  result  of  typhoid  confusional 
insanity  is  very  infrequent.  Death  from  suicide  or  accident 
should  not  be  forgotten  as  a  possibility. 

Stupokous  Insanity.  Sometimes,  though  infrequently,  cases 
which  begin  as  confusional  insanity  merge  into  stupor,  the  ner- 
vous exhaustion  becoming  so  profound  that  the  mental  faculties  are 
finally  completely  suspended.  However,  cases  that  become  stu- 
porous differ  from  the  ordinary  confusional  cases  in  the  length  of 
the  developmental  period,  and  although  a  stage  of  confusion  is 
present  preceding  the  onset  of  stupor,  this  stage  is  usually  short. 
The  stuporous  form  is,  therefore,  well  defined  clinically,  but  bears 
close  relations  to  the  form  characterized  by  confusion. 

Stuporous  insanity  is  characterized  chiefly  by  a  more  or  less 
marked  abeyance  of  the  mental  faculties.  It  is  also  known  as 
acute  dementia  or  curable  dementia.  It  is  of  extremely  gradual 
development.  Several  weeks  usually  elapse  before  stupor  is  estab- 
lished, and  during  this  preliminary  period  the  patient  is  nervous, 
timid,  and  fearful,  sleeps  badly,  complains  of  headache,  and  is 
dull  of  comprehension.  Instead  of  gaining  in  weight,  as  does  the 
ordinary  case  of  typhoid  during  convalescence  from  the  fever,  he 
is  either  at  a  standstill  or  loses.  He  is  worried,  feels  ill,  and  loses 
his  appetite.  Soon  mental  confusion  makes  its  appearance.  As 
in  confusional  insanity  the  patient  loses  the  proper  appreciation  of 
his  surroundings.  He  believes  himself  to  be  away  from  home 
and  fails  to  recognize  the  persons  about  him,  and  after  a  time  this 
inability  to  interpret  his  surroundings  gives  way  to  an  inability  to 
appreciate  them  at  all.     The  patient  lies  motionless  in  bed,  indif- 


276     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

ferent  apparently  to  everything  about  him.  In  this  condition  he 
cannot  be  made  to  answer  questions  and  does  not  speak  sponta- 
neously. Emotionally  he  seems  placid  and  indifferent,  though  in 
some  cases  periods  are  present  during  which  transient  emotional 
movements,  excitement,  depression,  or  weeping  are  observed.  The 
face  is  relaxed,  flaccid,  and  expressionless.  He  is  utterly  helpless. 
Frequently  he  betrays  a  form  of  automatism  ;  he  may  remain  for 
some  time  in  the  position  in  which  he  has  been  placed  without 
moving.  Thus  the  arm  may  be  kept  elevated,  the  fingers  ex- 
tended, or  the  head  turned  to  one  side.  These  symptoms  are  often 
spoken  of  as  cataleptoid,  but  they  have,  of  course,  no  relation 
with  true  catalepsy.  Again,  while  the  great  majority  of  cases  are 
motionless,  a  very  limited  number  are  accompanied  by  agitation  or 
purposeless  movements.  The  feeding  of  the  patient  is  often  diffi- 
cult. At  times  he  will  swallow  food  that  is  placed  in  his  mouth, 
at  other  times  he  will  allow  it  to  remain  in  the  mouth,  making  no 
effort  at  swallowing,  or  will  allow  it  passively  to  escape  upon  the 
pillow.  In  many  cases  nasal  feeding  is  the  only  practicable  plan 
of  administering  nourishment,  and,  as  a  rule,  this  can  easily  be 
carried  out  and  answers  every  possible  purpose. 

The  physical  condition  of  the  patient  reveals  great  depression 
of  nutrition.  There  is  decided  loss  of  flesh,  coolness  or  coldness 
of  the  surface  and  at  times  a  subnormal  temperature.  The  features 
are  pale,  perhaps  slightly  cyanosed.  The  extremities  are  often 
bluish  and  sometimes  cedematous.  The  pulse  is  small  and  slow, 
the  respiration  shallow.  In  women  the  menses  cease.  Like  con- 
fusional  insanity,  stupor  is  an  affection  of  long  duration  ;  several 
months  are  always  required.  Convalescence  also  is  established 
very  gradually.  The  patient  begins  by  betraying  some  conscious- 
ness of  his  surroundings.  He  may  attempt  to  speak  or  make 
movements  of  expression.  He  also  begins  to  take  his  food  more 
readily,  brightens  up  a  little  toward  the  latter  part  of  the  day,  and 
little  by  little  comes  into  normal  relations  with  his  environment. 
Readiness  of  fatigue  persists  for  a  long  time,  and  there  are  fre- 
quent recurrences  of  mental  confusion  which  reveal  themselves 
either  in  the  patient's  actions  or  in  his  conversation.     Great  care 


THE  MENTAL  COMPLICATIONS.  277 

should  be  taken  to  conserve  the  strength  of  the  patient  as  much  as 
possible  by  the  avoidance  of  excitement  or  of  visitors.  While  by 
far  the  greater  number  of  cases  end  in  recovery,  this  is  not  the 
invariable  rule.  A  few  cases  pass  into  permanent  dementia  ;  in 
others  some  permanent  mental  impairment  persists,  and  in  a 
smaller  number  death  results,  due  either  to  the  gravity  of  the 
exhaustion  or  to  some  visceral  complication. 

3.  Cerebral  Asthenia,  Pseudo-dementia,  Pseudo-paresis. 
More  frequently,  perhaps,  than  any  other  complication  we  have 
following  typhoid  fever  a  condition  of  general  mental  enfeeble- 
ment.  This  is  generally  of  short  duration,  but  is  sometimes 
excessively  prolonged.  There  is  present  in  such  cases  a  slight, 
though  unmistakable,  weakness  of  the  intelligence  together  with 
abnormal  excitability  and  loss  or  impairment  of  emotional  con- 
trol. The  patient  does  not  comprehend  as  readily  as  normally,  is 
incapable  of  sustained  effort,  lacks  spontaneity  of  thought,  and 
laughs  or  cries  on  relatively  slight  provocation.  He  is  also  very 
readily  fatigued.  At  times  there  is  in  addition  a  diminution  in 
the  facility  and  readiness  of  speech.  Physical  symptoms  indica- 
tive of  weakness  are  also  present — e.  g.,  coldness  of  the  extremi- 
ties, cardiac  palpitation,  atonic  indigestion  and  persistent  sleep 
disturbances.  This  cerebral  asthenia  for  some  unexplained  reason, 
occasionally  follows  comparatively  mild  attacks  of  the  fever  and 
may  be  very  marked.  In  other  cases,  again,  in  which  the  attack 
has  apparently  been  of  great  severity,  these  symptoms  may  be 
entirely  absent. 

Instead  of  a  mere  mental  weakness  and  anenergia,  actual  men- 
tal obtusion  may  be  present,  and  this  mental  obtusion  may  become 
so  pronounced  as  to  lead  to  great  impairment  of  all  of  the  mental 
faculties — a  form  of  dementia.  This  is  not,  however,  a  true  de- 
mentia, but  one  in  which  the  mental  faculties  are  merely  sus- 
pended, not  obliterated.  It  is  properly  termed  a  pseudo-dementia. 
This  pseudo-dementia  lasts  many  months  and  at  times  even  one  or 
two  years.  Recovery  follows  in  the  majority  of  cases,  but  is  very 
gradual.  Sometimes  it  is  incomplete,  permanent  mental  impair- 
ment resulting.      Every  now  and   then   there   are   added   to   this 


278     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

background  of  dementia  symptoms  which  closely  resemble  those 
of  paresis.  Thus  there  may  be  present  great  muscular  weakness, 
ataxia  of  movement,  tremor  of  the  lips,  face,  or  extremities,1  and 
to  the  condition  of  obtusion,  hebetude,  and  mental  weakness 
already  present,  there  may  be  added  absurd  and  ambitious  delu- 
sions. This  feeble,  expansive  state  makes  the  resemblance  to 
paresis  appear  very  striking  and  often  misleading.  The  pseudo- 
paresis  of  typhoid  fever  may  occasion  difficulty  in  diagnosis  if  the 
physician  be  in  ignorance  of  the  etiology.  However,  the  detailed 
history  of  the  case,  the  presence  or  absence  of  the  Argyll-Robert- 
son pupil,  the  condition  of  the  optic  nerve  as  revealed  by  the 
ophthalmoscope,  are  among  the  factors  which  should  be  considered. 
Pseudo-paresis  following  typhoid  fever  almost  always  terminates 
in  recovery ;  besides  the  course  of  the  disease  is  different  from  that 
of  paresis.     The  mental  loss,  too,  is  not  as  profound  or  as  real. 

4.  Insanity  with  Systematized  Delusions  Resembling  Para- 
noia. A  very  limited  number  of  cases  of  insanity  following 
typhoid  fever  present  a  series  of  more  or  less  well-systematized 
delusions.  These  delusions  are  at  times  remains  of  the  fever  deli- 
rium which  have  persisted.  At  other  times  they  arise  during 
convalescence.  The  patient  may  give  well-connected  accounts  of 
frightful  persecutions,  of  murders,  hangings,  etc.  The  delusions 
are  almost  invariably  of  a  depressive  character,  and  appear  to  be 
connected  with  painful  or  terrifying  hallucinations.  Such  cases 
have  been  described  by  Midler,2  Hurd,3  and  others.  They  are 
distinguished  from  true  paranoia  not  only  by  the  peculiar  etiology, 
but  also  by  the  fact  that  the  delusions  are  not  firmly  fixed,  but 
often  shifting  in  character,  and  also  by  the  fact  that  sooner  or 
later,  as  soon  as  the  general  condition  of  the  patient  improves,  the 
delusions  vanish.  Recovery  may,  however,  not  always  ensue,  and 
progressive  mental  impairment,  Avith  final  dementia,  may  be  the 
result.     Such  an  outcome,  however,  appears  to  be  exceptional. 

5.  True  Mania  or  True  Melancholia.  In  addition  to  the 
various  forms  of  mental  disorder  above  described,  and  which  are 

1  Christian,  Westphal,  Kegis.  2  Muller,  Loc.  cit. 

3  Hurd,  American  Journal  of  Insanity,  July,  1892. 


THE  MENTAL  COMPLICATIONS.  279 

evidently  associated  with  the  excessive   nervous  weakness  and, 

perhaps,  the  profound  intoxication  of  the  typhoid  infection,  pure 
insanities  are  every  now  and  then  observed.  In  other  words,  true 
mania  or  true  melancholia  may  arise  subsequent  to  typhoid  fever. 
Owing  to  the  loose  way  in  which  the  terms  mania  and  melancholia 
arc  employed  by  many  medical  writers,  many  cases  of  so-called 
mania  and  melancholia  have  been  placed  upon  record  as  resulting 
from  typhoid  fever.  A  close  examination,  however,  reveals  that 
they  are  in  most  instances  cases  of  an  insanity  of  exhaustion,  gen- 
erally confusional  insanity,  which  have  been  classed  as  mania  or 
melancholia,  according  to  the  presence  of  mental  excitement  on  the 
one  hand  or  mental  depression  on  the  other.  Pure  mania  or  pure 
melancholia,  as  a  result  of  typical  typhoid  fever  is  excessively  rare. 
For  instance,  typical  melancholia  with  excessive  psychic  pain  and 
self -accusatory  delusions,  as  typified  by  the  delusion  of  the  unpar- 
donable sin,  is  almost  never  met  with.  This  is  also  true  of  pure 
mania  as  typified  by  excessive  exaltation,  expansion,  and  increased 
rapidity  in  the  flow  of  ideas,  without  hallucinations  or  confusion. 
Further,  cases  of  the  pure  insanities  following  typhoid  fever  do 
not,  as  a  rule,  like  the  insanities  of  exhaustion,  develop  immedi- 
ately after  or  within  a  short  period  of  the  defervescence  of  the 
fever,  but  at  rather  later  periods — weeks  and  months  afterward. 
It  is  exceedingly  probable  that  when  a  pure  insanity  does  follow 
typhoid  fever  it  is  an  indirect  sequel.  In  other  words,  the  post- 
typhoid condition  of  asthenia  merely  offers  a  suitable  soil  in  which 
true  mania  or  true  melancholia  may  develop  in  subjects  predis- 
posed to  these  affections  by  heredity.  We  should  remember  that 
mania  and  melancholia  are  largely  determined  by  heredity  and 
only  need  a  condition  of  depraved  nervous  nutrition  in  order  to 
make  themselves  manifest. 

Prognosis  in  General.  The  prognosis  of  the  various  mental 
complications  of  typhoid  fever  depends  largely  upon  the  period  at 
which  the  symptoms  appear.  Prodromal  insanity,  especially  grave 
prodromal  delirium,  tends  in  a  large  number  of  cases,  one-third, 
according  to  Adler,  to  end  fatally.  The  prognosis  of  the  compli- 
cations arising  during  the  fever  is  almost  uniformly  good.      The 


280     COMPLICATIONS  AND  SEQUELS  OF  TYPHOID  FEVER. 

fever-delirium,  the  confusion,  the  expansive  and  ambitious  ideas 
vanish  with  the  disappearance  of  the  fever.  The  various  forms  of 
mental  derangement  which  occur  as  sequela?  of  typhoid  fever  also 
offer  a  favorable  prognosis  as  a  whole.  The  great  majority  of  cases 
of  post-typhoid  confusional  or  stuporous  insanity  make  a  good  re- 
covery, but  this  is  not  by  any  means  the  constant  result.  Instead 
of  a  continuous  progress  toward  recovery,  there  may  be  a  series  of 
relapses,  followed  by  incomplete  recovery  or  cases  may  pass  into 
hopeless  chronicity  and  dementia.  This,  however,  as  has  already 
been  pointed  out,  is  the  outcome  in  a  small  percentage  of  cases 
only.  Pilgrim1  states  that  in  his  opinion  only  about  50  per  cent, 
of  cases  due  to  typhoid  fever  recover,  while  20  per  cent,  die  from 
exhaustion,  and  30  per  cent,  gravitate  into  chronic  insanity.  These 
statements,  however,  are  not  borne  out  by  the  experience  outside 
of  the  asylums.  The  percentage  of  favorable  results  is  really 
much  greater. 

It  may  be  not  uninteresting  to  add  a  paragraph  as  to  the  re- 
markable effects  which  follow  typhoid  fever  when  attacking  those 
who  are  already  insane.  In  quite  a  number  of  such  cases,  irre- 
spective of  the  special  form  of  insanity,  recovery  follows  typhoid 
fever.  In  others,  again,  long-continued  improvement  ensues ;  in 
a  smaller  number  temporary  improvement,  and  in  others  still  no 
change  whatever  is  observed.  ISasse,2  Wise,3  Keay,4  Charon,5  and 
others  have  placed  on  record  quite  a  number  of  cases  of  recovery.6 
The  interesting  fact  of  recovery  of  insanity  after  typhoid  fever  is 
comparable  to  the  effects  of  other  infectious  processes,  such  as  ery- 
sipelas, and  also  to  the  results  occasionaly  following  trauma  and 
surgical  operations  on  the  insane.     Even  in  so  grave  a  mental 

1  State  Hospital  Bulletin,  New  York,  Utica,  1896,  vol.  i.  p.  50. 

2  Loc.  cit. 

3  State  Hospital  Bulletin,  New  York,  Utica,  1896,  vol.  i.  p.  63. 

4  Journal  of  Mental  Sciences,  1896,  vol.  xlii.  p.  267. 

5  Charon,  Arch,  de  Neurol.,  1896,  i.  p.  330. 

6  Hyvert,  Arch,  de  Neurol.,  1895,  vi.  p.  103,  believes  on  the  other  hand,  that 
typhoid  fever  affects  the  mental  state  of  the  insane  to  a  less  degree  than  do  other 
infections. 


THE  MENTAL  COMPLICATIONS.  281 

disease  as  paresis,  au  attack  of  erysipelas  or  a  trauma  is  occasionally 
followed  by  a  striking  and  remarkable  remission  of  symptoms  ; 
similar  statements  may  be  made  with  regard  to  melancholia  and 
other  forms  of  mental  disease  associated  with  depression  and  im- 
paired nutrition.  In  cases  in  which  typhoid  fever  fails  to  cure  or 
to  improve  the  mental  symptoms,  the  psychosis  already  presenl 
does  not  appear  to  be  affected  injuriously.  At  least  this  is 
NasseV  conclusion.  One  case  under  the  observation  of  this  writer 
presented  a  paroxysm  of  delirium  of  short  duration  ;  in  none  of 
the  others,  five  in  number,  in  which  the  typhoid  infection  failed 
to  cure  the  insanity,  did  any  unfavorable  result  supervene.  Nasse1 
further  observed  a  greater  percentage  of  recoveries  from  typhoid 
fever  in  the  insane  than  among  the  hospital  attendants.  Wise," 
on  the  other  hand,  found  the  mortality  30  per  cent,  among  the 
insane  and  24  per  cent,  among  the  employes.  These  data  evi- 
dently do  not  point  to  any  lessened  degree  of  vulnerability  on 
the  part  of  the  insane. 

1  Hyvert,  Arch,  de  Neurol.,  1895,  vi.  p  103. 

2  State  Hospital  Bulletin,  New  York,  Utica,  vol.  i.  p.  69. 


INDEX. 


A  BDOMINAL,  catarrh,  70 
XX   pain,  123 
Abnormal  eruptions  in  typhoid  fever, 

166 
Abortive  typhoid  fever,  38,  73 
Abrupt  onset,  56 
Abscess,  alveolar,  205 

appendicular,  148 

of  liver,  209 

of  lung,  97,  1S2 

of  mesentery  glands,  218 

of  parotid  gland,  208 

subphrenic,  218 

of  retroperitoneal  glands,  218 

subdiaphragmatic,  218 
Absence  of  fever,  70 

of  intestinal  lesions,  115 
Acute,  delirium,  267,  269 

endocarditis,  100 

nephritis,  l04 

pleurisy  in  onset,  51 

pulmonary    tubercular     consolida- 
tion, 50 
Afebrile  abdominal  catarrh,  70 
Age,  mortality  in  advanced,  36 
Albuminuria,  104 
Alcoholic  neuritis,  225 
Alimentary  canal  in  convalescence,  202 
in  developed  stage,  109 
in  onset,  53 
Alveolar  abscess,  205 
Amaurosis,  235 
Ambiguous  period,  64 
Anus,  gangrene  of,  208 
Aphasia,  162,  234 
Aphthous  inflammations,  205 
Appendicitis,  143,  257 
Apyretic  typhoid  fever,  71 
Ascending  myelitis,  228 
Asthenia,  101 


BED,  fever,  181 
sores,  169 
Bilious  fever,  54 
Blood,  bacillus  of  Eberth  in,  103 

in  developed  stage,  101 
Bloodv  stools,  78 
Boils,  "241 
Bowel,  cicatricial  contraction  of,  204 

gangrene  of,  203 

thermometer  in,  221 
Bronchitis,  95 


pAEBUNCLES,  241 

\J     Carphologia,  164 
Catarrh,  afebrile  abdominal,  70 
Cerebral,  asthenia,  277 

embolism,  160 

thrombosis,  160 
Changing  fortunes,  period  of,  64 
Children,  relapse  in,  177 

typhoid  fever  in,  27 
Chill  in  onset,  43 
Chills,  75 
Cholangitis,  130 
Cholecystitis,  42,  89,  211 
Chorea,  237 

Cicatricial  constriction  of  bowel,  204 
Circulation  in  convalescent  stage,  182 

in  developed  stage,  98 
Coal-tar  products,  chill  producing,  78 
Collapse,  78,  79,  100,  127 
Complicating  infections,  78 
Complications,  mental,  265 
Conditions  which   ape  typhoid    fever, 

253 
Confusional  insanity,  271 
Congestion,  hypostatic,  96 
Constipation,  120,  202 
Convalescence,  period  of,  174 
Convalescent  stage,  circulation  in,  182 
respiratory  affections  in,  181 
Convulsions,  162 
Course  of  fever  in  relation  to  prognosis, 

83 
Croupous  pneumonia,  67,  96 
Cystitis,  109 


DEATH,  sudden,  184,  188 
Delirium  in  developed  stage,  149 
in  onset,  57 
Desquamation  of  skin,  248 
Developed  stage,  63 

alimentarv  canal  in,  109 
blood  in,  101 
circulation  in,  98 
respiratory  system  in,  85 
Diagnosis  of  perforation,  129 
Diarrhoea,  80,  202 

in  typhoid  fever,  120 
serous,  55 
Dicrotism,  98 

Diphtheria  of  intestine.  203 
Dislocation  of  joints,  251 
Duration,  262 


284 


INDEX. 


EMBOLISM,  185 
cerebral,  160 
Emphysema  of  mediastinum,  93 
Empyema,  98 
Endarteritis,  187 
Endocarditis,  185,  186 
acute,  100 
ulcerated,  80 
Eosinophils,  80 
Epididymitis,  194 
Epilepsy  in  relation  to  typhoid  fever, 

165 
Epistaxis,  88 

late,  89 
Eruptions,  abnormal,  166' 
Eruptive  diseases  in  the  course  of  fever, 

171 
Erysipelas,  241 
Exhaustion,  101 


FAINTNESS,  78 
Fall  of  temperature,  sudden,  78 
Fever,  bilious,  54 

gastric,  54 

infantile  remittent,  54 

pneumo-typhoid,  47 

remittent  malarial,  74 

septic,  75 

worm,  54 
Foetus,  infection  by  typhoid  fever,  33 
Forme  cardiaque,  99 
Frequency  of  hemorrhages,  123 

of  typhoid  fever  in  children,  27 


GALL-BLADDER,  80 
Gallstones,  213 
Gangrene,  170 

of  anus,  208 

of  bowel,  203 

of  extremities,  192 

of  lung,  97,  98,  182 

of  mouth,  205 

of  perineum,  208 

of  skin,  241 

of  tongue,  206 

superficial,  169 
Gastric  fever,  54 

symptoms  in  onset,  54 
Genito-urinary   complications    of   con- 
valescence, 193 

tract  in  developed  stage,  104 
Glossitis,  205 
Green  stools,  121 


HEMATURIA,  52,  104 
Headache,  152 
Heart  muscle  in  tvphoid  fever,  183 
Hebetude,  150 


Hemiplegia,  229 
Hemoptysis,  97 
Hemorrhages,  123 

frequency  of,  123 

from  stomach,  111 

in  children,  125 

intestinal,  78 
Hemorrhagic  diathesis,  170 

eruptions,  170 

infarction  of  lungs,  96 

nephritis,  104 
Hemorrhoidal  arteries,  thrombosis  of, 

207 
Hernia,  scrotal,  132 

ventral,  132 
Herpes  labialis,  170 
High  temperatures,  66 
Hyperpyrexia,  66 
Hypostatic  congestion  of  lungs,  96 
Hysteria,  163,  238 
Hysterical  convulsions,  152 


IMMUNITY,  262 
I     Indigestion,  202 
Infantile  remittent  fever,  54 
Infarction,  185 

of  lung,  96 
Infections,  complicating,  78 
Influenza,  79 
Insanity,  152,  268_ 
Insidious  perforation,  128 
Intercurrent  relapse,  67,  177 
Intestinal  hemorrhage,  78 

lesions,  absence  of,  115 
Intestines  in  typhoid  fever,  115 


JAUNDICE,  219 
J     Joints,  250 


KIDNEY,  miliary  abscess  of,  107 
Kidneys,  in  onset  of  fever,  52 
Knee-jerks,  absence  of,  164 


T  APAROTOMY  in  perforation,  135 
Li     Laryngeal  form  of  typhoid,  51 
paralysis,  235 
ulceration,  90 
Laryngo-typhus,  91 

typhoid,  51 
Larynx,  necrosis  of,  94 

perichondritis  of,  89 
Late  epistaxis,  89 
Leucocytes  in  complications,  102 
Linea  albican tes.  249 
Liver,  abscess  of,  209 
Lobular  pneumonia,  95 
Localized  atrophy  of  skin,  249 


ISDEX. 


285 


Lung,  abscess  of,  182 

gangrene  of,  182 
Lungs,  hemorrhagic  infarction  of,  96 

hypostatic  congestion  of,  96 

tuberculosis  of,  79 

MAIDSTONE  epidemic,  121 
Malaria,  253 
Malarial  fever,  remittent,  74 
Maniacal  delirium,  58 
Measles,  complicating,  173 
Mediastinal  emphysema,  93 
Mediastinum,  suppuration  of,  93 
Melancholia,  278, 
Meningitis,  153 
Mental  complications.  265 

disturbances,  234 
Mesentery  glands,  abscess  of,  218 
Miliary  abscess  of  kidney,  107 

tuberculosis,  96,  256 
Morbidity,  decrease  of,  18 
Mortality,  decrease  of,  18 

of  perforation,  130 

relation  of  age  to,  36 
Mountain  fever,  260 
Mouth,  gangrene  of,  205 
Multiple  abscess  of  liver,  210 

relapses,  180 
Myelitis,  ascending,  228 
Mvostitis,  237 


YTECKOSIS  of  larynx,  94 
11     Nephritis,  acute,  104 

hemorrhagic,  104 
Nephro-typhoid,  52 
Nervous  symptoms  in  convalescence,  221 

in  developed  stage,  149 

in  onset,  56 
Neuritis,  165 

peripheral,  221 
Noma,  204 

G^DEMA  of  thorax,  249 
-j     'Esophagus,  inflammation  of,  110 
ulceration  of,  110,  206 
Onset,  37 

abrupt,  56 
chill  in,  43 
delirium  in,  57 
in  alimentary  canal,  53 
in  kidneys,  52 
nervous  symptoms  in,  56 
respiratory  infection  in,  47 
rigor  in,  43 
skin  in,  62 
temperature  in,  37 
unusual  temperature  variations  in, 
40 
Orchitis,  193 


PAIN,  abdominal,  123 
Paralysis,  165,  221 
agitans,  235 
laryngeal,  235 
of  vocal  chords,  235 
pseudo-hypertrophic,  23S 
Paranoia,  27" 

Parotid  gland,  abscess  of,  208 
Parotitis,  209 

Percentage  of  perforation,  130 
Perforation,  78,  126 
diagnosis  of,  129 
of  bowel,  202 
treatment  of,  135 
Pericarditis,  188 
Perichondritis  of  larynx,  89 
Perineum,  gangrene  of,  208 
Period,  ambiguous,  64 
of  convalescence,  174 
of  "steep  curves,"  64 
Peripheral  neuritis,  221 
Peritoneum,  tuberculosis  of,  79 
Peritonitis,  129,  204 
Pharyngeal   involvement  in  developed 

stage,  109 
Pharvngo-tvphoid,  53 
Phlebitis,  67,  191 

of  calf  of  leg,  193 
Pleurisy,  67,  97 

acute,  in  onset,  51 
Pneumonia,  croupous,  96 

lobular,  95 
Pneumothorax,  97 
Pneumo-typhoid  fever,  47 
Pregnancv  complicating  tvphoid  fever, 
32,"  64 
typhoid  fever  during,  32 
Profuse  urinary  flow,  109 
Prognosis,   course  of  fever  in   relation 
to,  83 
in  post-typhoid  insanity,  279 
Pseudo-dementia.  277 

hypertrophic  paralysis,  238 
paresis,  277 
Puerperal  septicaemia,  259 
Pulmonary  abscess,  97 

tubercular  consolidation,  50 
Pulse  rate,  98 
Pvelitis,  107 
Pyemia,  80 
Pylephlebitis,  211 
Pyonephrosis,  109 
Pyuria,  107 


RAPID  pulse,  99 
Recrudescence,  174 
Relapse,  174 

from  gall-bladder  infection,  214 
in  children.   177 
intercurrent,  67,  177 


286 


INDEX. 


Relation  of  age  to  mortality,  36 
Remittent  malarial  fever,  74 

typhoid  fever,  74 
Respiratory   affections   in   convalescent 
stage,  181 

infection  in  onset,  47 

system  in  developed   stage  of  dis- 
ease, 85 
Retention  of  urine,  53 
Retroperitoneal  glands,  abscess  of,  218 
Rigor,  75,  181 

in  onset,  43 
Rose  rash,  80,  165 

SCARLET  fever,  248 
complicating  typhoid,  171 
Scrotal  hernia  in  typhoid  fever,  132 
Second  attacks,  262 
Septic  fever,  75 
Septicaemia,  80 
Skin  in  convalescence,  241 

localized  atrophy  of,  249 

in  onset,  62 

in  well-developed  stage,  165 
Spleen,  affections  of,  103 

enlargement  of,  220 

rupture  of,  220 
Spleno-typhoid,  103 
"Steep  curves,"  64 
Stomach,  110 

typhoid  ulcers  of,  111 

hemorrhage  of,  111 
Stools,  bloody,  78 

green.  121 
Strabismus,  235 
Stupor,  268 

Stuporous  insanity,  275 
Submaxillary  glands  involved,  110 
Subphrenic  abscess,  218 
Subsultus  tendinum,  164 
Sudamina,  168 
Sudden  death,  184,  188 

fall  of  temperature,  78 

rises  in  temperature,  57 
Sudoral  typhoid  fever,  44 
Suffocative  attacks,  92 
Suppuration  of  mediastinum,  93 
Syphilis,  80 
Systematized  delusions,  278 

TACHE  bleuatre,  73,  169 
cerebrale,  168 
Temperature,  absence  of  febrile,  70 
in  convalescence,  174 
in  developed  disease,  63 
in  onset,  37 
in  children,  42 
rises  in,  67 
sudden  fall  of,  78 
variations  from  usual  in  onset,  40 


Tetany,  238 

Thermometer  in  bowel,  221 
Thorax,  oedema  of,  249 
Thrombosis,  182 
cerebral,  160 

of  hemorrhoidal  arteries,  207 
Thyroid  gland,  249 
Tongue,  gangrene  of,  206 
Treatment  of  perforation,  135 
Tremor,  235 
Trichinosis,  80 
True  mania,  278 
Tubercular  consolidation,  50 
Tuberculosis,  95,  185,  256 
of  lungs,  79 
of  peritoneum,  79 
Typhoid  bacilli  in  urine,  108 
fever,  abortive,  38,  73 

apyretic,  71 

change  in  type  of,  27 

conditions  resembling,  253 

constipation  in,  120 

diarrhoea  in,  120 

eruptions,  166 

general  considerations  of,  17 

in  children,  27 

in  pregnancy,  32 

infection  of  fetus  by,  33 

intestines  in,  115 

laryngeal  form,  51 

low  temperatures  in,  70 

remittent,  74 

sudoral,  44 
"Typhoid-spine,"  238 
Typho-malarial  fever,  81 
Typhus,  laryngo,  91 
levissimus,  73 

ULCER  of  stomach,  111 
Ulcerative  endocarditis,  80 
Ulceration  and  diarrhoea,   relation   of, 
121 
of  larynx,  90 
oesophageal,  110,  206 
Urine,  retention  of,  53 

typhoid  bacilli  in,  108 
Urticaria,  168 

VARICOSITY  of  subcutaneous  veins 
192 
Varieties  of  onset,  37 
Veins,  varicosity  of,  192 
Ventral  hernia  in  typhoid  fever,  132 
Violent  diarrhoea  in  onset,  55 
Vocal  cords,  paralysis  of,  235 
Vomiting,  55,  111 


w 


ORM  fever,  54 


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BROCKWAY  (FRED.  J.).    A  POCKET  TEXT-BOOK  OF  ANATOMY.    12mo. 

of  about  400  pages,  richly  illustrated.     Shortly. 

BRUCE    (J.    MITCHELL).     MATERIA    MEDIC  A    AND    THERAPEUTICS. 

New  (6th)  edtion.     In  one  12mo.  volume  of  600  pages.     Just  ready.     Cloth,   $1.50,  net. 
See  Students'  Series  of  Manuals,  page  14. 

PRINCIPLES  OF  TREATMENT.     In  one  octavo  volume  of  625  pages.     Just 


Ready.     Cloth,  $3.75,  net. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth  American 
from  the  fourth  English  edition.  In  one  imperial  octavo  volume  of  1040  pages,  with  727 
illustrations.     Cloth,  $6.50 ;  leather,  $7.50. 

BUMSTEAD  (F.  J.)  AND  TAYLOR  (R.  W.).  THE  PATHOLOGY  AND 
TREATMENT  OF  VENEREAL  DISEASES.  See  Taylor  on  Venereal  Diseases, 
page  15. 

BURCHARD  ( HENRY  H. ) .  DENTAL  PA THOLOG Y  AND  THERAPEUTICS, 
INCLUDING  PHARMACOLOGY.  Handsome  octavo,  575  pages,  with  400  illus- 
trations.    Cloth,  $5  ;  leather,  $6,  net. 

BURNETT  (CHARLES  H.).  THE  EAR:  ITS  ANATOMY,  PHYSIOLOGY 
AND  DISEASES.  A  Practical  Treatise  for  the  Use  of  Students  and  Practitioners. 
Second  edition.  In  one  8vo.  volume  of  580  pages,  with  107  illustrations.  Cloth,  $4 ; 
leather,  $5. 

CARTER  (R.  BRUDENELL)  AND  FROST  (W.  ADAMS).  OPHTHALMIC 
SURGERY.  In  one  pocket-size  12mo.  volume  of  559  pages,  with  91  engravings  and 
one  plate.     Cloth,  $2.25.     See  Series  of  Clinical  Manuals,  page  13. 

CASPARI  (CHARLES,  JR.).  A  TREATISE  ON  PHARMACY.  For  Students 
and  Pharmacists.  In  one  handsome  octavo  volume  of  680  pages,  with  288  illustrations. 
Cloth,  $4.50. 

CHAPMAN  ( HENRY  C. ) .  A  TREA TISE  ON  HUMAN  PHYSIOLOG  Y.  New 
(2d)  edition.  In  one  octavo  volume  of  921  pages,  with  595  illustrations.  Just  ready. 
Cloth,  $4.25  ;  leather,  $5.25,  net. 


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CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIOLOGICAL 
AND  PATHOLOGICAL  CHEMISTRY.  In  one  handsome  octavo  volume  of  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  $3.50. 

CHEYNE  (W.  WATSON).  THE  TREATMENT  OF  WOUNDS,  ULCERS 
AND  ABSCESSES.    In  one  12mo.  volume  of  207  pages.     Cloth,  $1.25. 

CHEYNE  (W.  WATSON)  AND  BURGHARD  (F.  F.).  SURGICAL  TREAT- 
MENT. In  seven  octavo  volumes,  illustrated.  Volume  I,  just  ready.  299  pages  and 
66  engravings.  Cloth,  §3.00,  net.  Volume  II,  just  ready.  3S2  pages,  141  engravings. 
Cloth,  §4.00,  net.  Volume  III.  Just  Ready.  300  pages,  100  engravings.  Cloth,  §3.50,  net. 
Vol.  IV.     In  Press. 

CLARKE  (W.  B.)  AND  LOCKWOOD  (C.  B.):     THE  DISSECTOR'S  MANUAL. 

In  one  12mo.  volume  of  396  pages,  with  49  engravings.     Cloth,  $1.50.     See  Students'  Series 
of  Manuals,  page  14. 

CLELAND  (JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF  THE 
HUMAN  BODY.     In  one  12mo.  volume  of  178  pages.     Cloth,  $1.25. 

CLINICAL  MANUALS.     See  Series  of  Clinical  Manuals,  page  13. 

CLOUSTON  (THOMAS  S.).  CLINICAL  LECTURES  ON  MENTAL  DIS- 
EASES.  New  (5th)  edition.     Crown  8vo.,  of  736  pages  with  19  colored  plates.     Cloth, 

$4.25,  net. 

JUST*  Folsom's  Abstract  of  Laws  of  U.  S.  on  Custody  of  Insane,  octavo,  $1.50,  is  sold  in 
conjunction  with  Clouston  on  Mental  Diseases  for  $5.00,  net,  for  the  two  works. 

CLOWES    (FRANK).  AN  ELEMENTARY    TREATISE    ON  PRACTICAL 

CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALYSIS.    From  the 

fourth  English  edition.  In  one  handsome  12mo.  volume  of  387  pages,  with  55  engrav- 
ings.    Cloth,  §2.50. 

COAKLEY  (CORNELIUS  G.).  THE  DIAGNOSIS  AND  TREATMENT  OF 
DISEASES  OF  THE  NOSE,  THROAT,  NASO- PHARYNX  AND  TRACHEA. 
In  one  12mo.  volume  of  526  pages,  with  92  engravings,  and  2  colored  plates.  Cloth, 
§2.75,  net. 

COATES  (W.  E.,  Jr.).  A  POCKET  TEXT-BOOK  OF  BACTERIOLOGY 
AND  HYGIENE.     12mo.,  of  about  350  pages  with  many  illustrations.     Shortly. 

COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  volume  of  829 
pages,  with  339  engravings.     Cloth,  §5.50 ;  leather,  §6.50. 

COLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY  AND  PATH- 
OLOGY. With  Notes  and  Additions  to  adapt  it  to  American  Practice.  By  Thos.  C. 
Stellwagen,  M.A.,  M.D.,  D.D.S.  In  one  handsome  octavo  volume  of  412  pages,  with 
331  engravings.     Cloth,  §3.25. 

COLLINS  (C.  P.).  A  POCKET  TEXT-BOOK  OF  MEDICAL  DIAGNOSIS. 
12mo.  of  about  350  pages.     Shortly. 

COLLINS  (H.  D.)  AND  ROCKWELL  (W.  H.,  JR.).  A  POCKET  TEXT- 
BOOK OF  PHYSIOLOGY.  12mo.,  of  316  pages,  with  153  illustrations.  Just 
Ready.     Cloth,  §1.50,  net;  flexible  red  leather,  §2.00,  net. 

CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DISEASES 
OF  CHILDREN.    Sixth  edition.     8vo.  719  pages.     Cloth,  $5.25 ;  leather,  $6.25. 

CORNIL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNOSIS  AND 
TREA  TMENT.  Translated,  with  Notes  and  Additions,  by  J.  Henry  C.  Simes,  M.D., 
and  J.  William  White,  M.D.  In  one  8vo.  volume  of  461  pages,  with  84  illustrations. 
Cloth,  $3.75. 


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CROCKETT  <M.  A.).  A  POCKET  TEXT-BOOK  OF  DISEASES  OF 
WOMEN.  12mo.  of  3G8  pages,  with  107  illustrations.  Just  Ready.  Cloth,  SI. 50,  net. 
Flexible  Red  Leather,  $2.00,  net. 

CROOK  JAMES  K. ,.  MINERAL  WATERS  OF  UNITED  STATES.  Octavo 
574  pages.     Just  ready.     Cloth,  §3.50,  net. 

CULBRETH  I  DAVID  M.  R.  i .     MA  TERIA  MEDIC  A  AND  PHARMACOL  OGT. 

In  one  handsome  octavo  volume  of  812  pages,  with  445  engravings.     Cloth,  $4.75. 

CUSHNY  (ARTHUR  R.  i  A  TEXT-ROOK  OF  PHARMACOLOGY  AND 
THERAPEUTICS.  Octavo  of  728  pages,  with  47  illustrations.  Just  ready.  Cloth, 
$3.75,  net. 

DALTON  (JOHN  C).  A  TREATISE  ON  HUMAN  PHYSIOLOGY.  Seventh 
edition, thoroughly  revised.  Octavo  of  722  pages, with  252  engravings.  Cloth,  $5;  leather,$6. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.  In  one  hand- 
some 12mo.  volume  of  293  pages.     Cloth,  $2. 

DAVENPORT  (F.  H.).  DISEASES  OF  WOMEN.  A  Manual  of  Gynecology. 
For  the  use  of  Students  and  General  Practitioners.  New  (3d)  edition.  In  one  hand- 
some 12mo.  volume,  387  pages  and  150  engravings.     Cloth,  $1.75,  net. 

DAVIS  (F.H.).  LECTURES  ON  CLINICAL  MEDICINE.  Second  edition.  In 
one  12mo.  volume  of  287  pages.     Cloth,  §1.75. 

DAVIS  EDWARD  P.).  A  TREATISE  ON  OBSTETRICS.  For  Students  and 
Practitioners.  In  one  very  handsome  octavo  volume  of  546  pages,  with  217  engravings, 
and  30  full-page  plates  in  colors  and  monochrome.     Cloth,  $5 ;  leather,  $6. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER.  In  one  large  octavo  volume  of  700 
pages,  with  300  engravings.     Cloth,  $4. 

DENNIS  i FREDERIC  S.)  AND  BILLINGS  (JOHN  S.).  A  SYSTEM  OF 
SURGERY.  In  Contributions  by  American  Authors.  In  four  very  handsome  octavo 
volumes,  containing  3652  pages,  with  1585  engravings,  and  45  full-page  plates  in  colors 
and  monochrome.  Per  volume,  cloth,  86 ;  leather,  S7 ;  half  Morocco,  gilt  back  and 
top,  $8.50.     For  sale  by  subscription  only.     Full  prospectus  free. 

DERCUM  (FRANCIS  X.),  Editor.  A  TEXT-BOOK  ON  NERVOUS  DIS- 
EASES. By  American  Authors.  In  one  handsome  octavo  volume  of  1054  pages,  with 
341  engravings  and  7  colored  plates.     Cloth,  $6 ;  leather,  $7,  net. 

DE  SCHWEINITZ  (GEORGE  E.).  THE  TOXIC  AMBLYOPIAS ;  THEIR 
CLASSIFICATION,  HISTORY,  SYMPTOMS,  PATHOLOGY  AND  TREAT- 
MENT. Very  handsome  octavo,  240  pages,  46  engravings,  and  9  full-page  plates  in 
colors.     Limited  edition,  de  luxe  binding,  $4,  net. 

DRAPER  |  JOHN  C. ) .  MEDICAL  PHYSICS.  A  Text-book  for  Students  and  Prac- 
titioners of  Medicine.     Octavo  of  734  pages,  with  376  engravings.     Cloth,  §4. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  A  new  American,  from  the  twelfth  London  edition,  edited  by  Stanley 
Boyd,  F.R.C.S.     Large  octavo,  965  pages,  with  373  engravings.     Cloth,  $4  ;  leather,  $5. 

DUANE  (ALEXANDER).  A  DICTIONARY  OF  MEDICINE  AND  THE 
ALLIED  SCIENCES.  Comprising  the  Pronunciation,  Derivation  and  Full  Explan- 
ation of  Medical,  Dental,  Pharmaceutical  and  Veterinary  Terms.  Together  with  much 
Collateral  Descriptive  Matter,  Numerous  Tables,  etc.  New  ( 3d )  edition.  Square  octavo 
volume  of  652  pages  with  8  colored  plates.  Just  Ready.  Cloth,  $3.00,  net;  limp 
leather,  $4.00,  net. 

DUDLEY  (E.  C).  A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  GYNECOLOGY.  For  Students  and  Practitioners.  New  (2d)  edition.  In  one 
very  handsome  octavo  volume  of  717  pages,  with  4-">3  engravings,  of  which  47  are 
colored,  and  8  full  page  plates  in  colors  and  monochrome.  Just  Ready.  Cloth,  $5.00,  net; 
leather,  $6.00,  net;  half  morocco,  $6.50,  net. 

DUNCAN  (J.  MATTHEWS).  CLINICAL  LECTURES  ON  THE  DISEASES 
OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital.  In  one  octavo  volume  of 
175  pages.     Cloth,  $1.50. 

Philadelphia,  706.  708  and  710  Sansom  St.— New  York,  111  Fifth  Avenue. 


6  LEA    BROTHERS    &    CO.'S    PUBLICATIONS. 

DUNGLISON  (ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCIENCE. m  Con- 
taining a  full  Explanation  of  the  Various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Medical  Chemistry,  Pharmacy,  Pharmacology,  Therapeutics,  Medicine,  Hygiene,  Dietetics. 
Pathology,  Surgery,  Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecology, 
Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  etc.,  etc.  By  Robeey  Denqli- 
son,  M.D.,  LL.D.,  late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  Col- 
lege of  Philadelphia.  Edited  by  Richard  J.  Denglison,  A.M.,  M.D.  Twenty-second 
edition,  thoroughly  revised  and  greatly  enlarged  and  improved,  with  the  Pronunciation, 
Accentuation  and  Derivation  of  the  Terms.  With  Appendix.  Imperial  octavo  of  about 
1400  pages.     Shortly. 

DUNHAM  (EDWARD  K.).     MORBID  AND  NORMAL  HISTOLOGY.     Octavo, 

450  pages,  with  360  illustrations.     Cloth,  S3. 25,  net. 

NORMAL  HISTOLOGY.      Xew   (2d)   edition.     Octavo,  319  pages,  with  244 

illustrations.     Just  Ready.     Cloth,  82.50,  net. 

EDES  (ROBERT  T.).  TEXT-BOOK  OF  THERAPEUTICS  AND  MATERIA 
MEDIC  A.     In  one  8vo.  volume  of  544  pages.     Cloth,  $3.50 ;  leather,  $4.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for  Students  and 
Practitioners.  In  one  handsome  8vo.  volume  of  576  pages,  with  148  engravings. 
Cloth,  S3 ;  leather,  S4. 

EGBERT  (SENECA).     HYGIENE  AND  SANITATION.     In  one  12mo.  volume  of 

359  pages,  with  63  illustrations.     Cloth,  S2.25,  net. 

ELLIS  (GEORGE  VINER).  DEMONSTRATIONS  IN  ANATOMY.  Being  a 
Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection.  From  the  eighth  and  revised 
English  edition.     Octavo,  716  pages,  with  249  engravings.     Cloth,  $4.25 ;  leather,  $5.25. 

EMMET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRACTICE  OF 
G  YNMCOL  OGY.  For  the  use  of  Students  and  Practitioners.  Third  edition,  enlarged 
and  revised.     8vo.  of  880  pages,  with  150  original  engravings.     Cloth,  85 ;  leather,  86. 

ERICHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SURGERY.  A  new 
American  from  the  eighth  enlarged  and  revised  London  edition.  In  two  large  octavo 
volumes  containing  2316  pages,  with  984  engravings.     Cloth,  89 ;  leather,  $11. 

ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY.  See  American  Text-books 
of  Dentistry,  page  2. 

EVANS  (DAVID  J.).     A  POCKET  TEXT-BOOK  OF  OBSTETRICS.     12mo. 

of  about  300  pages,  amply  illustrated.     Shortly. 

FARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS.  Fourth 
American  from  fourth  English  edition,  revised  by  Frank  Woodbury;  M.D.  In  one 
12mo.  volume  of  581  pages.     Cloth,  82.50. ; 

FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE  EAR.  Fourth 
edition.     Octavo,  391  pages,  with  73  engravings  and  21  colored  plates.     Cloth,  83.75. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  MEDICINE.  New  (7th)  edition,  thoroughly  revised  by  Frederick  P.  Henry, 
M.D.     In  one  large  8vo.  volume  of  1143  pages,  with  engravings.     Cloth,  85 ;  leather,  $6. 

A  MANUAL  OF  AUSCULTATION  AND  PERCUSSION ;  of  the  Physi- 
cal Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Fifth 
edition,  revised  by  James  C.  Wieson,  M.D.  In  one  handsome  12mo.  volume  of  274 
pages,  with  12  engravings. 

A   PRACTICAL    TREATISE    ON  THE  DIAGNOSIS  AND    TREAT- 


MENT OF  DISEASES  OF   THE   HEART.    Second  edition,  enlarged.     In  one 
octavo  volume  of  550  pages.     Cloth,  84. 

A   PRACTICAL   TREATISE  ON  THE  PHYSICAL  EXPLORATION 


OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING 
THE  RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  octavo  vol- 
ume of  591  pages.     Cloth,  84.50. 

MEDICAL  ESSA  YS.    In  one  12mo.  volume  of  210  pages.     Cloth,  81.38. 

ON  PHTHISIS :  ITS  MORBID  ANA  TO  MY,  ETIOL  OGY,  ETC.     A  Series 


of  Clinical  Lectures.     In  one  8vo.  volume  of  442  pages.     Cloth,  83.50. 


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FOLSOM  (C.  P.).  AN  ABSTRACT  OF  STATUTES  OF  U.  S.  ON  CUSTODY 
OF  THE  INSANE.  In  one  8vo.  volume  of  108  pages.  Cloth,  $1.50.  With  Clouston 
on  Mental  Diseases  (see  page  4  i,  at  $5.00,  net,  for  the  two  works. 

FORMULARY,  THE  NATIONAL.  See  Still- ,  Maisch  &  Coupon's  National  Dispensar 
tory,  page  14. 

FORMULARY,  POCKET.     See  page  1. 

FOSTER  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  New  (6th)  and 
revised  American  from  the  sixth  English  edition.  In  one  large  octavo  volume  of  923 
pages,  with  257  illustrations.     Cloth,  §4.50 ;  leather,  $5.50. 

FOTHERGILL  (J.  MILNER).  THE  PRACTITIONER'S  HAND-BOOK  OF 
TREATMENT.  Third  edition.  In  one  handsome  octavo  volume  of  664  pages. 
Cloth,  $3.75  ;  leather,  $4.75. 

FOWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEMISTRY  {IN- 
ORGANIC AND  ORGANIC).  Twelfth  edition.  Embodying  Watts'  Physical  and 
Inorganic  Chemistry.  In  one  royal  12mo.  volume  of  1061  pages,  with  168  engravings,  and 
1  colored  plate.     Cloth,  $2.75  ;  leather,  $3.25. 

FRANKLAND  (E.)  AND  JAPP  (F.  R.).  INORGANIC  CHEMISTRY.  In  one 
handsome  octavo  volume  of  677  pages,  with  51  engravings  and  2  plates.  Cloth,  $3.75 ; 
leather,  $4.75. 

FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  ORGANS  IN  THE 
MALE.  In  one  very  handsome  octavo  volume  of  238  pages,  with  25  engravings  and 
8  full-page  plates.     Cloth,  $2. 

FULLER  (HENRY).  ON  DISEASES  OF  THE  L  UNGS  AND  AIR-PASSA  GES. 
Their  Pathology,  Physical  Diagnosis,  Symptoms  and  Treatment.  From  second  English 
edition.     In  one  8vo.  volume  of  475  pages.     Cloth,  $3.50. 

GALLAUDET  (BERN  B.).  A  POCKET  TEXT-BOOK  ON  SURGERY. 
12mo.  of  about  400  pages,  with  many  illustrations.     Shortly. 

GANT  ( FREDERICK  JAMES ) .  THE  STUDENT'S  SURGER  Y.  A  Multum  in 
Parvo.     In  one  square  octavo  volume  of  845  pages,  with  159  engravings.     Cloth,  $3.75. 

GERRISH  (FREDERIC  H.).      A   TEXT-BOOK  OF  ANATOMY.     By   American 

Authors.     Edited  by  Frederic  H.  Gerrish,  M.  D.  In  one  imp.  octavo  volume  of  915 

pages,   with  950  illustrations  in  black  and  colors.  Cloth,  $6.50;  flexible  water-proof, 
$7  ;  sheep,  $7.50,  net. 

GIBBES  (HENEAGE).  PRACTICAL  PATHOLOGY  AND  MORBID  HIS- 
TOLOG  Y.   Octavo  of  314  pages,  with  60 illustrations,  mostly  photographic.   Cloth,  $2.75. 

GOULD  (A.  PEARCE).     SURGICAL  DIAGNOSIS.     In  one  12mo.  volume  of  589 

pages.     Cloth,  $2.     See  Students'  Series  of  Manuals,  page  14. 
GRAY    (HENRY).      ANATOMY,    DESCRIPTIVE   AND    SURGICAL.      New 

American  edition  thoroughly  revised.     In  one  imperial  octavo  volume  of  1239  pages, 

with  772  large  and  elaborate  engravings.     Price  with  illustrations  in  colors,  cloth,  $7  ; 

leather,  $8.     Price,  with  illustrations  in  black,  cloth,  $6  ;  leather,  $7. 

GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY  AND  MOR- 
BID ANATOMY.  New  (8th)  American  from  eighth  and  revised  English  edition. 
Oct.  595  pages,  with  215  engravings  and  a  colored  plate.     Cloth,  $2.50,  net. 

GREENE  (WILLIAM  H.).  A  MANUAL  OF  MEDICAL  CHEMISTRY.  For 
the  Use  of  Students.  Based  upon  Bowman's  Medical  Chemistry.  In  one  12mo.  volume 
of  310  page*,  with  74  illustrations.     Cloth,  $1.75. 

GRINDON  JOSEPH).  A  POCKET  TEXT-BOOK  OF  SKIN  DISEASES. 
12mo.  of  .">•"><)  pages,  with  many  illustrations.     Shortly. 

GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DISEASES, 
INJURIES  AND  MALFORMATIONS  OF  THE  URINARY  BLADDER, 
THE  PROSTATE  GLAND  AND  THE  URETHRA.  Third  edition,  revised  by 
Samuel  W.  Gross,  M.D.      Octavo  of  574  pages,  with  170  illustrations.     Cloth,  $4.50. 

HABERSHON  (S.  0.).  ON  THE  DISEASES  OF  THE  ABDOMEN,  comprising 
those  of  the  Stomach,  CEsophagus,  Caecum,  Intestines  and  Peritoneum.  Second  Amer- 
ican from  the  third  English  edition.  In  one  octavo  volume  of  554  pages,  with  11  engrav- 
ings.    Cloth,  $3.50. 

Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Avenue. 


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HALL  (WINFIELD  S.).  TEXT-BOOK  OF  PHYSIOLOGY.  Octavo,  672  pages, 
with  343  engravings  and  6  colored  plates.  Just  Ready.  Cloth,  $4.00,  net;  leather, 
§5.00,  net. 

HAMILTON  ( ALLAN  McL ANE ) .  NER  VO  US  DISEASES,  THEIB  DESCRIP- 
TION  AND  TBEATMENT.  Second  and  revised  edition.  In  one  octavo  volume  of 
598  pages,  with  72  engravings.     Cloth,  $4. 

HARD  AWAY  (W.  A.).  MANUAL  OF  SKIN  DISEASES.  New  (2d)  edition. 
In  one  12mo.  volume,  560  pages  with  40  illustrations  and  2  colored  plates.     Cloth, 

$2.25,  net. 

HARE  (HOB ART  AMORY).  A  TEXT-BOOK  OF  PB ACTIO AL  THERA- 
PEUTICS,  with  Special  Reference  to  the  Application  of  Remedial  Measures  to  Disease 
and  their  Employment  upon  a  Rational  Basis.  With  articles  on  various  subjects  by  well- 
known  specialists.  New  (8th)  and  revised  edition.  In  one  octavo  volume  of  796  pages, 
with  37  engravings  and  3  colored  plates.    Just  Beady.  Cloth,  $4.00,  net;  leather,  $5.00,  net. 


PB  ACTIO  AL  DIAGNOSIS.  The  Use  of  Symptoms  in  the  Diagnosis  of  Dis- 
ease. iS'ew  (4th)  edition,  revised  and  enlarged.  In  one  octavo  volume  of  623  pages, 
with  205  engravings,  and  14  full-page  plates.     Cloth,  $5,  net. 

Editor.     A  SYSTEM  OF  PRACTICAL  THERAPEUTICS.     By  American 


and  Foreign  Authors.  In  a  series  of  contributions  by  eminent  practitioners.  In  four 
large  octavo  volumes  comprising  4600  pages,  with  476  engravings.  Vol.  IV.,  now  ready. 
Regular  price,  Vol.  IV.,  cloth,  $6;  leather,  $7;  half  Russia,  $8.  Price  Vol.  IV.  to 
former  or  new  subscribers  to  complete  work,  cloth,  $5  ;  leather,  $6 ;  half  Russia,  $7. 
Complete  work,  cloth,  $20  ;  leather,  $24  ;  half  Russia,  $28.  For  sale  by  subscription  only. 
Full  prospectus  free  on  application  to  the  publishers. 

ON  THE  MEDICAL  COMPLICATIONS  AND  SEQUELAE  OF  TYPHOID 


FEVEB    Octavo,  276  pages,  21  engravings,  and2  full-page  plates.     Cloth,  $2.40,  net. 

HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo.  volume,  669  pages, 
with  144  engravings.     Cloth,  $2.75 ;  half  bound,  $3. 

A   HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.    In  one  12mo. 

volume  of  310  pages,  with  220  engravings.     Cloth,  $1.75. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.     Comprising  Manuals 


of  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and 
Obstetrics.  Second  edition.  In  one  royal  12mo.  volume  of  1028  pages,  with  477  illus- 
trations.    Cloth,  $4.25;  leather,  $5. 

HAYDEN  (JAMES  R.).  A  MANUAL  OF  VENEREAL  DISEASES.  New  (2d) 
edition.     In  one  12mo.  volume  of  304  pages,  with  54  engravings.     Cloth,  $1.50,  net. 

HAYEM  (GEORGES)  AND  HARE  (H.  A.).  PHYSICAL  AND  NATURAL 
THERAPEUTICS.  The  Remedial  Use  of  Heat,  Electricity,  Modifications  of  Atmos- 
pheric Pressure,  Climates  and  Mineral  Waters.  Edited  by  Prof.  H.  A.  Hake,  M.D. 
In  one  octavo  volume  of  414  pages,  with  113  engravings.     Cloth,  $3. 

HERMAN  (G.  ERNEST).  FIRST  LINES  IN  MIDWIFERY.  12mo.,  198  pages' 
with  80  engravings.     Cloth,  $1.25.     See  Students'  Series  of  Manuals,  page  14. 

HERMANN  ( L . ) .  EXPERIMENTAL  PHARMA  CO  LOGY.  A  Handbook  of  the 
Methods  for  Determining  the  Physiological  Actions  of  Drugs.  Translated  by  Robert 
Meade  Smith,  M.D.     In  one  12mo.  vol.  of  199  pages,  with  32  engravings.     Cloth,  $1.50. 

HERRICK  (JAMES  B.).  A  HANDBOOK  OF  DIAGNOSIS.  In  one  handsome 
12mo.   volume  of  429  pages,  with  .80  engravings  and  2  colored  plates.     Cloth,  $2.50. 

HILL  (BERKELEY).    SYPHILIS  AND  LOCAL  CONTAGIOUS  DISORDERS. 

In  one  8vo.  volume  of  479  pages.     Cloth,  $3.25. 

HILLIER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES.  Second  edition. 
In  one  royal  12mo.  volume  of  353  pages,  with  two  plates.     Cloth,  $2.25. 

HIRST  (BARTON  C.)  AND  PIERSOL  (GEORGE  A.).  HUMAN  MONSTROS- 
ITIES. Magnificent  folio,  containing  220  pages  of  text  and  illustrated  with  123  engrav- 
ings and  39  large  photographic  plates  from  nature.  In  four  parts,  price  each,  $5.  Limited- 
edition.     For  sale  by  subscription  only. 


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HOBLYN  ( RICHARD  D.)-  A  DICTIONARY  OF  THE  TERMS  USED  IN 
MEDICINE  AND  THE  COLLATERAL  SCIENCES.  New  (13th)  edition.  In 
one  12mo.  volume  of  845  pages.     Just  Ready.     Cloth,  S3. 00,  net. 

HODGE  (HUGH  L.).  ON  DISEASES  PECULIAR  TO  WOMEN,  INCLUDING 
DISPLACEMENTS  OF  THE  UTERUS.  Second  and  revised  edition.  In  one 
8vo.  volume  of  519  pages,  with  illustrations.     Cloth,  §4.50. 

HOFFMANN  (FREDERICK)  AND  POWER  (FREDERICK  B.).  A  MANUAL 
OF  CHEMICAL  ANAL  YSIS,  as  Applied  to  the  Examination  of  Medicinal  Chemicals 
and  their  Preparations.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one 
handsome  octavo  volume  of  621  pages,  with  179  engravings.     Cloth,  $4.25. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Principles  and 
Practice.  A  new  American  from  the  fifth  English  edition.  Edited  by  T.  Pickering 
Pick,  F.R.C.S.  In  one  handsome  octavo  volume  of  1008  pages,  with  428  engravings. 
Cloth,  $6 ;  leather,  $7. 

A  SYSTEM  OF  SURGERY.     With  notes  and  additions  bv  various  American 


authors.  Edited  by  John  H.  Packard,  M.  D.  In  three  very  handsome  8vo.  volumes 
containing  3137  double-columned  pages,  with  979  engravings  and  13  lithographic  plates. 
Per  volume,  cloth,  $6;  leather,  §7  ;  half  Russia.  $7.50.     For  sale  by  subscription  only. 

HORNER  (WILLIAM  E.).  SPECIAL  ANATOMY  AND  HISTOLOGY.  Eighth 
edition,  revised  and  modified.  In  two  large  8vo.  volumes  of  1007  pages,  containing  320 
engravings.     Cloth,  $6. 

HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER.  In  one  octavo 
volume  of  308  pages.     Cloth,  $2.50. 

HUTCHISON  (ROBERT)  AND  RAINY  (HARRY).  CLINICAL  METHODS. 
An  Introduction  to  the  Practical  Study  of  Medicine.  In  one  12mo.  volume  of  562  pages, 
with  137  engravings  and  8  colored  plates,     Cloth,  $3.00. 

HYDE  (JAMES  NEVINS).  A  PRACTICAL  TREATISE  ON  DISEASES  OF 
THE  SKIN.  New  (5th)  edition,  thoroughly  revised.  Octavo,  866  pages,  with  111 
engravings  and  24  full-page  plates,  8  of  which  are  colored.  Just  Ready.  Cloth,  $4.50, 
net;  leather,  $5.50,  net;  half  morocco,  $6.00,  net. 

JACKSON  ( GEORGE  THOMAS ) .  THE  READ  Y-REFERENCE  HANDB  0 OK 
OF  DISEASES  OF  THE  SKIN.  New  (3d)  edition.  12mo.  volume  of  637  pages, 
with  75  engravings,  and  one  colored  plate.     Cloth,  $2.50,  net. 

JAMIESON  (W.  ALLAN).  DISEASES  OF  THE  SKIN.  Third  edition.  Octavo, 
656  pages,  with  1  engraving  and  9  double-page  chromo-lithographic  plates.     Cloth3  $6. 

JEWETT  (CHARLES).  ESSENTIALS  OF  OBSTETRICS.  In  one  12mo.  volume 
of  356  pages,  with  80  engravings  and  3  colored  plates.     Cloth,  $2.25. 

THE  PRACTICE  OF  OBSTETRICS.   By  American  Authors.    One  large  octavo 

volume  of  763  pages,  with  441  engravings  in  black  and  colors,  and  22  full-page  colored 
plates.     Cloth,  $5.00,  net ;  leather,  $6.00,  net ;  half  morocco,  $6.50,  net. 

JONES  ( C .  HANDFIELD ) .  CLINICAL  OBSER  VA  TIONS  ON  FUNCTIONAL 
NER  VO  US  DISORDERS.  Second  American  edition.  In  one  octavo  volume  of  340 
pages.     Cloth,  $3.25. 

JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE  AND 
PR  A  CTICE.  Second  edition.  In  one  octavo  volume  of  549  pages,  with  201  engrav- 
ings, 17  chromo-lithographic  plates,  test-types  of  Jaeger  and  Snellen,  and  Holmgren's 
Color-Blindness  Test.     Cloth,  $5.50;  leather,  $6.50. 

KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.  See  American  Text-books  of 
Dentistry,  page  2. 

KING  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  New  (8th)  edition.  In  one 
12mo.  volume  of  612  pages,  with  264  illustrations.     Just  Ready.     Cloth,  $2.50,  net 

KLEIN  (E.).     ELEMENTS  OF  HISTOLOGY.     New  (5th)  edition.     In  one  pocket- 
size  12mo.   volume  of  506  pages,  with  296  engravings.     Cloth,  $2.00,  net. 
See  Students'  Series  of  Manuals,  page  14. 


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10  LEA    BROTHERS    &     CO.' S    PUBLICATIONS. 

LANDIS  'HENRY  G.).  THE  MANAGEMENT  OF  LABOR.  In  one  handsome 
12mo.  volume  of  329  pages,  with  28  illustrations.     Cloth,  §1.75. 

LA  ROCHE  (R.).  YELLOW  FEVER.  In  two  8vo.  volumes  of  1468  pages. 
Cloth,  §7. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C).  A  HANDY-BOOK  OF 
OPHTHALMLC  SUROERY.  Second  edition.  In  one  octavo  volume  of  227  pages, 
with  66  engravings.     Cloth,  §2.75. 

LEA  (HENRY  C).  CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF 
SPAIN;  CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMINATI; 
THE  ENDEMONIADAS ;  EL  SANTO  NINO  DE  LA  GUARDIA;  BRI- 
ANDA  DE  BARDAXI.    In  one  12mo.  volume  of  522  pages.     Cloth,  §2.50. 

A  HISTORY  OF  AURICULAR  CONFESSION  AND  INDULGENCES 

IN  THE  LATIN  CHURCH.     In  three  octavo  volumes  of  about  500  pages  each. 
Per  volume,  cloth,  S3.      Complete  work  fust  ready. 

■ FORMULARY   OF   THE   PAPAL    PENITENTIARY.     In    one  octavo 


volume  of  221  pages,  with  frontispiece.     Cloth,  §2.50. 


STUDIES  IN  CHURCH  HISTORY.  The  Rise  of  the  Temporal  Power- 
Benefit  of  Clergy — Excommunication.  New  edition.  In  one  handsome  12mo.  volume 
of  605  pages.     Cloth,  §2.50. 


SUPERSTITION  AND  FORCE;  ESSAYS  ON  THE  WAGER  OF  LAW, 

THE    WAGER    OF  BATTLE,   THE   ORDEAL   AND    TORTURE.     Fourth 
edition,  thoroughly  revised.     In  one  royal  12mo.  volume  of  629  pages.     Cloth,  §2.75. 

AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY  IN  THE 


CHRISTIAN  CHURCH.     Second  edition.     In  one  handsome  octavo  volume  of  685 
pages.     Cloth,  §4.50. 

LOOMIS  (ALFRED  L.)  AND  THOMPSON  (W.  GILMAN),  Editors.  A  SYS- 
TEM OF  PRA  CTICAL  MEDICINE.  In  Contributions  by  Various  American  Authors. 
In  four  very  handsome  octavo  volumes  of  about  900  pages  each,  fully  illustrated  in  black 
and  colors.  Complete  work  now  ready.  Per  volume,  cloth,  §5 ;  leather,  §6 ;  half 
Morocco,  §7.  For  sale  by  subscription  only.  Full  prospectus  free  on  application  to  the 
Publishers. 

LUFF  (ARTHUR  P.).  MANUAL  OF  CHEMISTRY,  for  the  use  of  Students  of 
Medicine.  In  one  12mo.  volume  of  522  pages,  with  36  engravings.  Cloth,  §2.  See 
Students'  Series  of  Manuals,  page  14. 

LYMAN  (HENRY  M.).  THE  PRACTICE  OF  MEDICINE.  In  one  very  hand- 
some octavo  volume  of  925  pages  with  170  engravings.     Cloth,  §4.75;  leather,  §5.75. 

LYONS  (ROBERT  D.).  A  TREATISE  ON  FEVER.  In  one  octavo  volume  of  362 
pages.     Cloth,  §2.25. 

MACKENZIE  (JOHN  NOLAND).  THE  DISEASES  OF  THE  NOSE  AND 
THROAT.     Octavo,  of  about  600  pages,  richly  illustrated.     Preparing. 

MAISCH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA  MEDICA. 
New  (7th)  edition,  thoroughly  revised  by  H.  C.  C.  Maisch,  Ph.G.,  Ph.D.  In  one  very 
handsome  12mo.  of  512  pages,  with  285  engravings.     Cloth,  §2. 50,  net. 

MALSBARY  (GEO.  E.).  A  POCKET  TEXT-BOOK  OF  THEORY  AND 
PRACTICE  OF  MEDICINE.  12mo.  405  pages,  with  45  illustrations.  Just  Ready. 
Cloth,  §1.75,  net;  flexible  red  leather,  §2.25,  net. 

MANUALS.  See  Students'  Quiz  Series,  page  14,  Students'  Series  of  Manuals,  page  14,  and 
Series  of  Clinical  Manuals,  page  13. 

MARSH  (HOWARD).  DISEASES  OF  THE  JOINTS.  In  one  12mo.  volume  of 
468  pages,  with  64  engravings  and  a  colored  plate.  Cloth,  §2.  See  Series  of  Clinical 
Manuals,  page  13. 

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LEA    BROTHERS    &     CO.'S    PUBLICATIONS.  11 

MARTIN  (EDWARD.)  SURGICAL  DIAGNOSIS.  One  12mo.  volume  of  400 
pages,  richly  illustrated.     Preparing. 

MARTIN  (WALTON)  AND  ROCKWELL  (W.  H.,  JR.).  A  POCKET  TEXT- 
BOOK OF  CHEMISTRY  AND  PHYSICS.  Vlmo.  366  pages,  with  137  illus- 
trations.    Just  ready.     Cloth,  $1.50,  net ;  flexible  red  leather,  $2.00,  net. 

MAY  (C.  H.).  MANUAL  OF  THE  DISEASES  OF  WOMEN.  For  the  use  of 
Students  and  Practitioners.  Second  edition,  revised  by  L.  S.  Rau,  M.D.  In  one  12mo. 
volume  of  360  pages,  with  31  engravings.     Cloth,  $1.75. 

MEDICAL  NEWS  POCKET  FORMULARY.     See  page  1. 

MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  INJURIES  OF 
NERVES  AND  THEIR  TREATMENT.  In  one  handsome  12mo.  volume  of  239 
pages,  with  12  illustrations.     Cloth  $1.75. 

MITCHELL  (S.  WEIR).  CLINICAL  LESSONS  ON  NERVOUS  DISEASES. 
In  one  verv  handsome  12mo.  volume  of  299  pages,  with  17  engravings  and  2  colored  plates. 
Cloth,  $2.50. 

MORRIS  (MALCOLM).  DISEASES  OF  THE  SKIN.  New  (2d)  edition.  In  one 
12mo.  volume  of  601  pages,  with  10  chromo-lithographic  plates  and  26  engravings. 
Cloth,  $3.25,  net. 

MULLER  (J.).     PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY.     In  one 

large  8vo.  volume  of  623  pages,  with  538  engravings.     Cloth,  $4. 50. 

MUSSER  (JOHN  H.).  A  PRACTICAL  TREATISE  ON  MEDICAL  DIAG- 
NOSIS, for  Students  and  Physicians.  New  (3d)  edition.  In  one  octavo  volume  of 
1082  pages,  with  253  engravings  and  48  full-page  colored  plates.  Just  Ready.  Cloth, 
$6.00,  net;  leather,  $7.00,  net. 

NATIONAL  DISPENSATORY.     See  Stille,  Maisch  &  Caspari,  page  14. 

NATIONAL    FORMULARY.       See  National  Dispensatory,  page  14. 

NATIONAL  MEDICAL  DICTIONARY.    See  Billings,  page  3. 

NETTLESHIP  (E.).  DISEASES  OF  THE  EYE.  New  (6th)  American  from  sixth 
English  edition.  Thoroughly  revised.  In  one  12mo.  volume  of  562  pages,  with  192 
engravings,  5  colored  plates,  test-types,  formulae  and  color-blindness  test.  Just  Ready. 
Cloth,  $2.25,  net. 

NICHOLS  (JOHN  B.)  AND  VALE  (F.  P.).  A  POCKET  TEXT-BOOK  OF 
HISTOLOGY  AND  PATHOLOGY.  12mo.  of  459  pages,  with  213  illustrations. 
Just  ready.     Cloth,  81.75,  net;  flexible  red  leather,  $2.25,  net. 

NORRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF  OPHTHAL- 
MOLOGY. In  one  octavo  volume  of  641  pages,  with  357  engravings  and  5  colored 
plates.     Cloth,  $5 ;  leather,  $6. 

OWEN  (EDMUND).    SURGICAL  DISEASES  OF  CHILDREN.     In  one  12mo. 

volume  of  525  pages,  with  85  engravings  and  4  colored  plates.     Cloth,  $2.     See  Series  of 
Clinical  Manuals,  page  13. 

PARK  (WILLIAM  H.).  BACTEBIOLOG  Y  IN  MEDICINE  AND  SURGER  Y. 
12mo.  688  pages,  with  87  engravings  in  black  and  colors  and  2  colored  plates.  Just 
Ready.     Cloth,  $3.00,  net. 

PARK  (ROSWELL),  Editor.  A  TREATISE  ON  SURGERY,  by  American  Authors. 
For  Students  and  Practitioners  of  Surgery  and  Medicine.  New  condensed  edition. 
In  one  large  octavo  volume  of  1261  pages,  with  625  engravings  and  38  plates.  Just 
Ready.  Cloth,  net,  $6. 00  ;  leather,  net,  $7.00.  K^^This  work  is  published  also  in  a 
large  edition,  comprising  two  octavo  volumes.  Vol.  I.,  General  Surgery,  799  pages,  with 
356  engravings  and  21  full-page  plates  in  colors  and  monochrome.  Vol.  II.,  Special 
Surgery,  796  pages,  with  451  engravings  and  17  full-page  plates  in  colors  and  mono- 
chrome.    Price  per  volume,  cloth,  $4.50;  leather,  $5.50,  net. 

PARVIN  (THEOPHILUS).  THE  SCIENCE  AND  ART  OF  OBSTETRICS. 
Third  edition.  In  one  handsome  octavo  volume  of  677  pages,  with  267  engravings  and 
2  colored  plates.     Cloth,  $4.25 ;  leather,  $5  25. 


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12  LEA    BROTHERS    &     CO.'S    PUBLICATIONS 


PEPPER'S  SYSTEM  OF  MEDICINE.    See  page  2. 

PEPPER  (A.  J.).  SURGICAL  PATHOLOGY.  In  one  12mo  volume  of  511  pages, 
with  81  engravings.     Cloth,  §2.     See  Students'  Series  of  Manuals,  page  14. 

PICK  (T.  PICKERING).  FRACTURES  AND  DISLOCATIONS.  In  one  12mo. 
volume  of  530  pages,  with  93  engravings.    Cloth,  $2.    See  Series  of  Clinical  3Ianuals,  p.  13. 

PLAYFAIR  (W.  S.).  A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE 
OF  MIDWIFERY.  New  (7th)  American  from  the  Ninth  English  edition.  In  one 
octavo  volume  of  700  pages,  with  207  engravings  and  7  full  page  plates.  Cloth,  §3.75, 
net;  leather,  §4.75,  net. 

THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRATION  4.ND 


HYSTERIA.     In  one  12mo.  volume  of  97  pages.     Cloth,  $1. 

OLITZER  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE  EAR 
AND  ADJACENT  ORGANS.  Second  American  from  the  third  German  edition. 
In  one  octavo  volume  of  748  pages,  with  330  original  engravings. 

POCKET  FORMULARY.    SeeTpage  1. 

POCKET  TEXT-BOOKS  Cover  the  entire  domain  of  medicine  in  sixteen  volumes  of 
350  to  450  pages  each,  written  by  teachers  in  leading  American  medical  colleges. 
Issued  under  the  editorial  supervision  of  Bekn  B.  Gallatjdet,  M.D.,  of  the  College  of 
Physicians  and  Surgeons,  New  York.  Thoroughly  modern  and  authoritative,  concise 
and  clear,  amply  illustrated  with  engravings  and  plates,  handsomely  printed  and 
bound.  The  series  is  constituted  as  follows  :  Anatomy  (preparing),  Physiology  (ready), 
Chemistry  and  Physics  (ready),  Histology  and  Pathology  (ready),  Materia  Medica, 
Therapeutics,  Medical  Pharmacy,  Prescription  Writing  and  Medical  Latin  (ready), 
Practice  (ready),  Diagnosis  (shortly),  Nervous  and  Mental  Diseases  (ready),  Surgery 
(preparing),  Genito-Urinary  and  Venereal  Diseases  {preparing),  Skin  Diseases 
(preparing),  Eye,  Ear,  Nose  and  Throat  (shortly),  Obstetrics  (shortly),  Gynecology 
(ready),  Diseases  of  Children  (ready),  Bacteriology  and  Hvgiene  (shortly).  For  further 
details  see  under  respective  authors  in  this  catalogue.  Special  circular  free  on  appli- 
cation. 

POTTS  (CHAS.  S.).  A  POCKET  TEXT-ROOK  OF  NERVOUS  AND 
MENTAL  DISEASES.  12mo.  of  455  pages,  with  88  illustrations.  Just  ready. 
Cloth,  §1.75,  net;  flexible  red  leather,  82.25,  net. 

PROGRESSIVE  MEDICINE.    See  page  1. 

PURDY  (CHARLES  W.).  BRIGHT' S  DISEASE  AND  ALLIED  AFFEC- 
TIONS OF  THE  KIDNEY.  In  one  octavo  volume  of  288  pages,  with  18  engrav- 
ings.    Cloth,  §2. 

PYE-SMITH  (PHILIP  H.).  DISEASES  OF  THE  SKIN.  In  one  12mo.  volume 
of  407  pages,  with  28  illustrations,  18  of  which  are  colored.     Cloth,  $2. 

QUIZ  SERIES.     See  Students'  Quiz  Series,  page  14. 

RALFE  (CHARLES  H.).  CLINICAL  CHEMISTRY.  In  one  12mo.  volume  of 
314  pages,  with  16  engravings.     Cloth,  f  1.50.     See  Students'  Series  of  Manuals,  page  14. 

RAMSBOTHAM  (FRANCIS  H.).  THE  PRINCIPLES  AND  PRACTICE  OF 
OBSTETRIC  MEDICINE  AND  SURGERY.  Imperial  octavo,  of  640  pages, 
with  64  plates  and  numerous  engravings  in  the  text.      Leather,  §7. 

REMSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEMISTRY. 
New  (5th)  edition,  thoroughly  revised.     In  one  12mo.  volume  of  326  pages.     Cloth,  $2. 

RICHARDSON   (BENJAMIN  WARD).     PREVENTIVE  MEDICINE.    In  one 

octavo  volume  of  729  pages.     Cloth,  $4;  leather,  §5. 

ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  New  (2d)  edition.  In  one  octavo  volume  of  838  pages,  with  474 
engravings  and  8  plates.     Just  Ready.     Cloth,  $4.25,  net;  leather,  §5.25,  net. 

THE  COMPEND  OF  ANATOMY.     For  use  in  the  Dissecting  Room  and  in 

preparing  for  Examinations.     In  one  16mo.  volume  of  196  pages.     Limp  cloth,  75  cents. 


Philadelphia,  706,  708  and  710  Sansom  St— New  York,  111  Fifth  Avenue. 


LEA    BROTHERS    &     CO.'S    PUBLICATIONS.  13 

ROSS  (JAMES).    A  HANDBOOK  OF  THE  DISEASES  OF  THE  NERVOUS 

SYSTEM.     In  one  handsome  octavo  volume  of  726  pages,  with  184  engravings.     Cloth, 
$4.50;  leather,  $5.50. 

SCHAFER  ( EDWARD  A. ) .  THE  ESSENTIA  LS  OF  HISTOL  OGY,  DESCRIP- 
TIVE AND  PRACTICAL.  For  the  use  of  Students.  New  (5th)  edition.  In  one 
handsome  octavo  volume  of  350  pages,  with  325  illustrations.    Cloth,  $3,  net. 

A    COURSE    OF  PRACTICAL    HISTOLOGY.     Second   edition.     In    one 


12mo.  volume  of  307  pages,  with  59  engravings.     Cloth,  $2.25. 

SCHLEIF  iWM.).  A  POCKET  TEXT-BOOK  OF  MATERIA  MEDICA, 
THERAPEUTICS,  PRESCRIPTION  WRITING.  MEDICAL  LATIN  AND 
MEDICAL  PHARMACY.  12mo.  352  pages.  Just  Ready.  Cloth,  $1.50,  net; 
flexible  red  leather,  $2.00,  net. 

SCHMITZ  AND  ZUMPT'S  CLASSICAL  SERIES. 

ADVANCED  LATIN  EXERCISES     Cloth,  60  cents;  half  bound,  70  cents. 
SCHMITZ' S  ELEMENTAR  Y  LA  TIN  EXERCISES.     Cloth,  50  cents. 
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NEPOS.     Cloth,  60  cents ;  half  bound,  70  cents. 
VIRGIL.     Cloth,  85  cents;  half  bound,  $1. 
CURTIUS.     Cloth,  80  cents;  half  bound.  90  cents. 

SCHOFIELD  (ALFRED  T.).  ELEMENTARY  PHYSIOLOGY  FOR  STU- 
DENTS. In  one  12mo.  volume  of  380  nages,  with  227  engravings  and  2  colored  plates. 
Cloth,  $2. 

SCHREIBER  (JOSEPH).  A  MANUAL  OF  TREATMENT  BY  MASSAGE 
AND  METHODICAL  MUSCLE  EXERCISE.  Translated  by  Walter  Mendel- 
son,  M.  D. ,  of  New  York.  In  one  handsome  octavo  volume  of  274  pages,  with  117  fine 
engravings. 

SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edition.  In  one 
octavo  volume  of  268  pages,  with  13  plates,  10  of  which  are  colored,  and  9  engravings. 
Cloth,  $2. 

SERIES  OF  CLINICAL  MANUALS.  A  Series  of  Authoritative  Monographs  on 
Important  Clinical  Subjects,  in  12mo.  volumes  of  about  550  pages,  well  illustrated.  The 
following  volumes  are  now  ready :  Yeo  on  Food  in  Health  and  Disease,  new  (2d) 
edition,  $2.50;  Carter  and  Frost's  Ophthalmic  Surgery,  $2.25;  Marsh  on  Diseases 
of  the  Joints,  $2 ;  Owen  on  Surgical  Diseases  of  Children,  $2 ;  Pick  on  Fractures  and 
Dislocations,  $2. 

For  separate  notices,  see  under  various  authors'  names. 

SERIES  OF  POCKET  TEXT-BOOKS.    See  page  12. 

SERIES  OF  STUDENTS'  MANUALS.    See  next  page. 

SIMON  (CHARLES  E.).  CLINICAL  DIAGNOSIS,  BY  MICROSCOPICAL 
AND  CHEMICAL  METHODS.  New  (3d)  and  revised  edition.  In  one  handsome 
octavo  volume  of  563  pages,  with  138  engravings  and  18  full-page  plates  in  colors. 
Just  Ready.     Cloth,  S3. 50,  net. 

SIMON  (W.).  MANUAL  OF  CHEMISTRY.  A  Guide  to  Lectures  and  Laboratory 
Work  for  Beginners  in  Chemistry.  A  Text-book  specially  adapted  for  Students  of  Phar- 
macy and  Medicine.  New  (6th)  edition.  In  one  8vo.  volume  of  536  pages,  with  46 
engravings  and  8  plates  showing  colors  of  64  tests.     Cloth,  $3.00,  net. 

SLADE  (D.  D.).  DIPHTHERIA;  ITS  NATURE  AND  TREATMENT.  Second 
edition.     In  one  royal  12mo.  volume,  158  pages.     Cloth,  $1.25. 

SMITH  (EDWARD).     CONSUMPTION;   ITS  EARLY  AND  REMEDIABLE 

STAGES.     In  one  8vo.  volume  of  253  pages,     (loth,  $2.25. 

SMITH  (J.  LEWIS).  A  TREATISE  ON  THE  DISEASES  OF  INFANCY 
AND  CHILDHOOD.  Eighth  edition,  thoroughly  revised  and  rewritten  and  greatly 
enlarged.  In  one  large  8vo.  volume  of  983  pages,  with  273  illustrations  and  4  full- 
page  plates.     Cloth,  $4.50  ;  leather,  $5.50. 


Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Avenue. 


14  LEA    BROTHERS    &     CO.'S    PUBLICATIONS. 

SMITH  (STEPHEN).     OPERATIVE  SURGERY.     Second  and  thoroughly  revised 

edition.     In  one  octavo  vol.  of  892  pages,  with  1005  engravings.     Cloth,  $4 ;  leather,  $5 

SOLLY  (S.  EDWIN).  A  HANDBOOK  OF  MEDICAL  CLIMATOLOGY. 
In  one  handsome  octavo  volume  of  462  pages,  with  engravings  and  11  full-page  plates, 
5  of  which  are  in  colors.     Cloth,  §4.00. 

STILLE  (ALFRED).  CHOLERA;  ITS  ORIGIN,  HISTORY,  CAUSATION, 
SYMPTOMS,  LESIONS,  PREVENTION  AND  TREATMENT  In  one  12mo. 
volume  of  163  pages,  with  a  chart  showing  routes  of  previous  epidemics.     Cloth,  $1.25. 

THERAPE  UTICS  AND  MA  TERIA  MEDIC  A.    Fourth  and  revised  edition. 


In  two  octavo  volumes,  containing  1936  pages.     Cloth,  §10 ;  leather,  $12. 

STILLE   (ALFRED),   MAISOH   (JOHN   M.)   AND   CASPARI   (CHAS.   JR.). 

THE  NATIONAL  DISPENSATORY:  Containing  the  Natural  History,  Chemistry, 
Pharmacy,  Actions  and  Uses  of  Medicines,  including  those  recognized  in  the  latest  Phar- 
macopoeias of  the  United  States,  Great  Britian  and  Germany,  with  numerous  references 
to  the  French  Codex.  Fifth  edition,  revised  and  enlarged  in  accordance  with  and  em- 
bracing the  new  U.  S.  Pharmacopoeia,  Seventh  Decennial  .Revision.  With  Supplement 
containing  the  new  edition  of  the  National  Formulary.  In  one  magnificent  imperial 
octavo  volume  of  2025  pages,  with  320  engravings  Cloth,  $7.25;  leather,  $8.  With 
ready  reference  Thumb-letter  Index.     Cloth,  $7.75;  leather,  $8.50. 

STIMSON  (LEWIS  A.).  A  MANUAL  OF  OPERATIVE  SURGERY.  New 
(4th)  edition.  In  one  royal  12mo.  volume  of  581  pages,  with  293  engravings.  Cloth,  $3.00, 
net.     Just  Ready. 

A  TREATISE  ON  FRACTURES  AND  DISLOCATIONS.  In  one  hand- 
some octavo  volume  of  831  pages,  with  326  engravings  and  20  full-page  plates.  Cloth, 
$5  ;  leather,  $6,  net. 

STUDENTS'  QUIZ  SERIES.  A  New  Series  of  Manuals  in  question  and  answer  for 
Students  and  Practitioners,  covering  the  essentials  of  medical  science.  Thirteen  volumes, 
pocket  size,  convenient,  authoritative,  well  illustrated,  handsomely  bound  in  limp  cloth, 
and  issued  at  a  low  price.  1.  Anatomy  (double  number);  2.  Physiology;  3.  Chemistry 
and  Physics ;  4.  Histology,  Pathology  and  Bacteriology ;  5.  Materia  Medica  and  Thera- 
peutics ;  6.  Practice  of  Medicine ;  7.  Surgery  (double  number) ;  8.  Genito-Urinary  and 
Venereal  Diseases ;  9.  Diseases  of  the  Skin ;  10.  Diseases  of  the  Eye,  Ear,  Throat  and 
Nose ;  11.  Obstetrics ;  12.  Gynecology ;  13.  Diseases  of  Children.  Price,  $1  each,  except 
Nos.  1  and  7,  Anatomy  and  Surgery,  which  being  double  numbers  are  priced  at  $1.75  each. 
Full  specimen  circular  on  application  to  publishers. 

STUDENTS'  SERIES  OF  MANUALS.  A  Series  of  Fifteen  Manuals  by  Eminent 
Teachers  or  Examiners.  The  volumes  are  pocket-size  12mos.  of  from  300-540  pages,  pro- 
fusely illustrated,  and  bound  in  red  limp  cloth.  The  following  volumes  may  now  be 
announced:  Herman's  First  Lines  in  Midwifery,  $1.25;  Luff's  Manual  of  Chemistry, 
$2;  Bruce's  Materia  Medica  and  Therapeutics  (sixth  edition),  $1.50,  net;  Gould's  Sur- 
gical Diagnosis,  §2;  Klein's  Elements  of  Histology  (5th  edition),  $2.00,  net;  Pepper's 
Surgical  Pathology,  $2;  Treves'  Surgical  Applied  Anatomy,  $2;  Ralfe's  Clinical 
Chemistry,  $1.50;  and  Clarke  and  Lockwood's  Dissector's  Manual,  $1.50. 
For  separate  notices,  see  under  various  authors'  names. 

STURGES  (OCTAVIUS).  AN  INTRODUCTION  TO  THE  STUDY  OF  CLIN- 
ICAL MEDICINE.     In  one  12mo.  volume.     Cloth,  $1.25. 

SUTTON  (JOHN  BLAND).  SURGICAL  DISEASES  OF  THE  OVARIES 
AND  FALLOPIAN  TUBES.  Including  Abdominal  Pregnancy.  In  one  12mo.  vol- 
ume of  513  pages,  with  119  engravings  and  5  colored  plates.     Cloth,  $3. 

TAIT  (LAWSON  .  DISEASES  OF  WOMEN  AND  ABDOMINAL  SURGERY 
Vol.  I.  contains  554  pages,  62  engravings,  and  3  plates.     Cloth,  $3. 

TANNER  (THOMAS  HAWKES).  ON  THE  SIGNS  AND  DISEASES  OF 
PREGNANCY.  From  the  second  English  edition.  In  one  octavo  volume  of  490  pages, 
with  4  colored  plates  and  16  engravings.     Cloth,  $4.25. 


Philadelphia,  706,  708  and  7/0  Sansom  St.— New  York,  111  Fifth  Avenue. 


LEA     BROTHERS    &     CO.'S    PUBLICATIONS.  15 

TAYLOR  (ALFRED  S.).  MEDICAL  JURISPRUDENCE.  New  American 
from  the  twelfth  English  edition,  specially  revised  by  Clark  Bell,  Esq.,  of  the  N.  Y. 
Bar.  In  one  octavo  volume  of  831  pages,  with  54  engravings  and  8  full-page  plates. 
Cloth,  $4.50;  leather,  $5.50. 

ON   POISONS    IN    RELATION    TO    MEDICINE    AND    MEDICAL 

JURISPRUDENCE.     Third  American  from  the  third  London  edition.     In  one  8vo. 
volume  of  788  pages,  with  104  illustrations.     Cloth,  $5.50;  leather,  $6.50. 

TAYLOR  (ROBERT  W.).  THE  PATHOLOGY  AND  TREATMENT  OF 
VENEREAL  DISEASES.  New  (2d)  edition.  In  one  very  handsome  octavo  volume 
of  about  800  pages,  with  about  230  engravings  and  many  colored  plates.     Shortly. 

A  PRACTICAL  TREATISE  ON  SEXUAL  DISORDERS  IN  THE  MALE 


AND  FEMALE.     New   (2d)  edition.     In  one  octavo  volume  of  434  pages,  with  91 
engravings  and  13  plates.     Just  Ready.     Cloth,  $3.00,  net. 

A    CLINICAL    ATLAS    OF    VENEREAL    AND    SKIN    DISEASES. 


Including  Diagnosis,  Prognosis  and  Treatment.  In  eight  large  folio  parts,  measuring 
14  x  18  inches,  and  comprising  213  beautiful  figures  on  58  full-page  chromo-lithographic 
plates,  85  fine  engravings,  and  425  pages  of  text.  Complete  work  now  ready.  Price  per 
part,  sewed  in  heavy  embossed  paper,  $2.50.  Bound  in  one  volume,  half  Russia,  $27  ; 
half  Turkey  Morocco,  $28.  For  sale  by  subscription  only.  Address  the  publishers.  Spec- 
imen plates  by  mail  on  receipt  of  10  cents. 

TAYLOR  (SEYMOUR).  INDEX  OF  MEDICINE.  A  Manual  for  the  use  of  Senior 
Students  and  others.    In  one  large  12mo.  volume  of  802  pages.     Cloth,  $375. 

THOMAS  (T.  GAILLARD)  AND  MUNDE  (PAUL  P.).  A  PRACTICAL 
TREATISE  ON  THE  DISEASES  OF  WOMEN.  Sixth  edition,  thoroughly 
revised  by  Paul  F.  Munde,  M.D.  In  one  handsome  octavo  volume  of  824  pages,  with 
347  engravings.     Cloth,  $5 ;  leather,  $6. 

THOMPSON  (W.  GILMAN).  A  TEXT-BOOK  OF  PRACTICAL  MEDICINE. 
For  Students  and  Practitioners.  In  one  handsome  octavo  volume  of  1012  pages,  with 
79  illustrations.     Just  Ready.     Cloth,  $5.00,  net;  leather,  $6.00,  net. 

THOMPSON  (SIR  HENRY).  CLINICAL  LECTURES  ON  DISEASES  OF 
THE  URINARY  ORGANS.  Second  and  revised  edition.  In  one  octavo  volume  of 
203  pages,  with  25  engravings.     Cloth,  $2.25. 

THE  PATHOLOGY  AND   TREATMENT  OF  STRICTURE  OF  THE 

URETHRA  AND  URINARY  FISTULA.  From  the  third  English  edition.  In 
one  octavo  volume  of  359  pages,  with  47  engravings  and  3  lithographic  plates.  Cloth, 
$3.50. 

THOMSON  (JOHN).  A  GUIDE  TO  THE  CLINICAL  EXAMINATION  AND 
TREATMENT  OF  SICK  CHILDREN.  In  one  crown  octavo  volume  of  350  pages 
with  52  illustrations.     Cloth,  $1.75,  net. 

TIRARD  (NESTOR).  MEDICAL  TREATMENT  OF  DISEASES  AND  SYMP- 
TOMS.    Handsome  octavo  volume  of  627  pages.     Just  Ready.     Cloth,  $4.00,  net. 

TODD  (ROBERT  BENTLEY).  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.     In  one  8vo.  volume  of  320  pages.    Cloth,  $2.50. 

TREVES  (FREDERICK).  OPERATIVE  SURGERY.  In  two  8vo.  volumes  con- 
taining 1550  pages,  with  422  illustrations.     Cloth,  $9 ;  leather,  $11. 


A  SYSTEM  OF  SURGERY.  In  Contributions  by  Twenty-five  English  Sur- 
geons. In  two  large  octavo  volumes,  containing  2298  pages,  with  950  engravings  and 
4  full-page  plates.     Per  volume,  cloth,  $8. 

SURGICAL  APPLIED    ANATOMY.     In  one  12mo.  volume  of  583  pages, 


with  61  engravings.     Cloth,  $2.     See  Students'  Series  of  Manuals,  page  14 

TUTTLE  (GEO.  M.).  A  POCKET  TEXT-BOOK  OF  DISEASES  OF 
CHILDREN  12mo.  374  pages,  with  5  plates.  Just  Ready.  Cloth,  $1.50,  net; 
flexible  red  leather,  $2.00,  net. 


Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Avenue. 


16  LEA    BROTHERS    &    CO.' S    PUBLICATIONS. 

VAUGHAN  (VICTOR  C.)  AND  NOVY  (FREDERICK  G.).  PTOMAINS, 
LEUCOMAINS,  TOXINS  AND  ANTITOXINS,  or  the  Chemical  Factors 'in  the 
Causation  of  Disease.     Third  edition.     In  one  12mo.  volume  of  603  pages. 

VISITING  LIST.  THE  MEDICAL  NEWS  VISITING  LIST  for  1900.  Four 
styles  :  Weekly  (dated  for  30  patients) ;  Monthly  (undated  for  120  patients  per  month) ; 
Perpetual  (undated  for  30  patients  each  week) ;  and  Perpetual  (undated  for  60  patients 
each  week).  The  60-patient  book  consists  of  256  pages  of  assorted  blanks.  The  first 
three  styles  contain  32  pages  of  important  data,  thoroughly  revised,  and  160  pages  of 
assorted  blanks.  Each  in  one  volume,  price,  $1.25.  With  thumb-letter  index  for  quick 
use,  25  cents  extra.  Special  rates  to  advance-paying  subscribers  to  The  Medical  News 
or  The  American  Journal  of  the  Medical  Sciences,  or  both.     See  page  1. 

WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND  PRAC- 
TICE OF  PHYSIC.  A  new  American  from  the  fifth  and  enlarged  English  edition, 
with  additions  by  H.  Hartshorne,  M.D.  In  two  large  8vo.  volumes  of  1840  pages,  with 
190  engravings.     Cloth,  $9  ;  leather,  $11. 

WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR  TO 
WOMEN.     Third  American  from  the  third  English  edition.     In  one  octavo  volume  of 

543  pages.     Cloth,  $3.75;  leather,  $4.75. 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 


HOOD.    In  one  small  12mo.  volume  of  127  pages.   "Cloth,  $1.    , 

WHARTON  (HENRY  R.).  MINOR  SURGERY  AND  BANDAGING.  New 
(4th)  edition.  In  one  12mo.  volume  of  596  pages,  with  502  engravings,  many  of  which 
are  photographic.     Just  Ready.     Cloth,  $3. 00,  net. 

WHITLA  (WILLIAM).  DICTIONARY  OF  TREATMENT,  OR  THERA- 
PEUTIC INDEX.  Including  Medical  and  Surgical  Therapeutics.  In  one  square 
octavo  volume  of  917  pages.     Cloth,  $4. 

WILLIAMS  (DAWSON).  MEDICAL  DISEASES  OF  INFANCY  AND 
CHILDHOOD.  In  one  12mo.  volume  of  629  pages,  with  18  illustrations.  Cloth, 
$2.50,  net. 

WILSON  (ERASMUS).  A  SYSTEM  OF  HUMAN  ANATOMY.  Anew  and 
revised  American  from  the  last  English  edition.  Illustrated  with  397  engravings.  In 
one  octavo  volume  of  616  pages.     Cloth,  $4 ;  leather,  $5. 

WINCKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED      In  one 

octavo  volume  of  484  pages.     Cloth,  $4. 

WIPPERN  (A.  G.)  AND  BALLENGER  (W.  L.).  A  POCKET  TEXT-BOOK 
OF  DISEASES  OF  THE  EYE,  EAR,  NOSE  AND  THROAT.  12mo.  of 
about  400  pages  with  many  illustrations.     Shortly. 

WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY  Translated  from  the 
eighth  German  edition,  by  Ira  Remsen,  M.D.  In  one  12mo.  volume  of  550  pages. 
Cloth   $3. 

YEARBOOK  OF  TREATMENT  FOR  1898.  A  Critical  Review  for  Practitioners  of 
Medicine  and  Surgery.  In  contributions  bv  24  well-known  medical  writers.  12mo.,  488 
pages.     Cloth,  $1  50. 

YEAR-BOOKS  OF  TREATMENT  for  1892,  1893,  1896,  and  1897,  similar  to  above. 
Each,  cloth,  $1.50- 

YEO  (I.  BURNEY).  FOOD  IN  HEALTH  AND  DISEASE.  New  (2d)  edition. 
In  one  12mo.  volume  of  592  pages,  with  4  engravings.  Cloth,  $2.50.  See  Series  oj 
Clinical  Manuals,  page  13. 

YOUNG  (JAMES  K.).  ORTHOPEDIC  SURGERY.  In  one  8vo  volume  of  475 
pages,  with  286  illustrations.     Cloth,  $4 ;  leather,  $5. 


Philadelphia,  706,  708  and  710  Sansom  St— New  York,  111  Fifth  Avenue. 


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